AF 447 Thread No. 8

[A33Zab]

BEA press release 30/05/2012 (http://www.bea.aero/en/enquetes/flight.af.447/pressrelease30may2012.en.php):


The BEA will publish the Final Report of the safety investigation on Thursday, 5 July, 2012 and at the same time will hold a press briefing.

[Clandestino]

You sure did notice, that we are discussing the "falling" here in this thread. So underneath all this talk about FBW modes, alerting systems, flightdeck ergonomics, way we did it on tactical fighters, French politics and spectacularly flawed hypotheses leading to absurd conclusions there is actually discussion about "the falling"? Forgive me for not having the patience to dig it out under all the rubble and being left with the impression "the falling" is the elephant in the room of this thread.

I have sat back and read the last umpteen posts and it seems there are two camps, both polarized in position - Airbus fans and Airbus not-fans.Absolutely. One can divide posters on this thread in any stereotypical way that suits himself. Me, being biased this way, would rather use another division: ones generally able to get their facts straight and ones only occasionally able to do so. E.g: by the time second interim report was made, the recorders, with most of the wreck, had not been found. From ACARS messages and recovered flotsam it was pretty clear way the final act of the tragedy started (clogged pitots) and the way it ended (high alpha and high RoD impact wih ocean) yet how one gets from unreliable airspeed to stalling into water was mystery. Nevertheless, interim 2 notices that high-altitude cases of blocked pitots did not occur in the storm cells but rather near them, as the crews were avoiding. Finding the CVR and DFDR did confirm that crew did circumnavigate the active storm cells and did not penetrate any of them. Still we have those sticking to old conjectures, nowadays disproved and best forgotten, that AF447 entered the storm.

You left out a critical piece of the answer to that question: they practice flying so they know how the aircraft works, in all modes. That means you need to experience what happens near the edges, in a controlled environment. Doing is a critical part of training!
Actual flying is a skill susceptible to rust, unless all you do is monitor what the robot does for you.Indeed I did but I did it on purpose. While I completely agree that hand-flying the aeroplane is a skill that can corrode quickly and deeply, I do not think it was a factor in AF447 demise. If pitch trace showed oscillation between 0° and 10°, I'd be inclined to say: "Well he was trying to get to 5° but he was too rusty to do that with any precision". Pitch and sidestick traces tell completely different story. It is almost as if the only thing CM2 could remember when stall warning went off was:

¡Arriba, siempre arriba!...while forgetting that all the sooo complicated aerodynamic equations, Penaud diagrams and atmospheric sciences tell very simple story: "The air up here is too thin for your wings and engines to support your weight. You can go down voluntarily and orderly or otherwise, but you will go down." People praising the benefits of unusual attitude recovery training often completely misunderstand the key point of it: it is not the motor skill of pulling and pushing timely, in correct sequence and precisely to get your aeroplane upright again; it is teaching one to quickly and correctly recognize the attitude and energy then promptly choose and implement the best way to get back to normal. What is taught is mental skill, not motor and it is a fine example of what the Bill Voss meant when he said: "It is not about better stick and rudder skills". Anyway, most of the general public have just fine motor skills to fly an aeroplane. Reason only small minority can successfully fly is not in hands; it is in heads. Flying is not an intellectual exercise; good pilot has to quickly and properly asses any situation he has gotten into and react promptly yet he absolutely must rely on his knowledge and intelligence, while not allowing the emotions, such as fear and excitement, to overwhelm him. Failing that, and reverting to medieval or even prehistoric strata of the brain, he will find out the human being is evolutionary completely unadapted to flight, with fatal consequences.

Anyway, without the benefit of the modern technology, medicine and psychology, eighty years ago there was a fine fellow who understood what it takes to be a pilot and that has not changed ever since or is likely to change soon:

Anyone can do the job when things are going right. In this business we play for keeps.

Interim 2 has some very interesting notes about the behaviour of the other A330/340 pilots during UAS:

The variations in altitude stayed within a range of more or less one thousand
feet. Five cases of a voluntary descent were observed, of which one was of
3,500 feet. These descents followed a stall warning;

(...)

Nine cases of triggering of the stall warning were observed.

(...)

The stall warning triggers when the angle of attack passes a variable threshold
value. All of these warnings are explicable by the fact that the airplane is in
alternate law at cruise mach and in turbulent zones. Only one case of triggering
was caused by clear inputs on the controls.
So out of thirtysomething cases analyzed, there was only one previous case where stall warning was activated because someone pulled, yet even then pull was turned into push and everybody lived to tell the story. Saying it were the bad pilots that made the difference between AF447 and all the other cases would be severely ignorant, as would be saying that it was the fault of the company and regulators to prepare the pilots for the eventuality. Real life, including flying, is a game of chances. It is not fair and we can load the dice, increase probabilities towards the desired outcome but we can never, ever eliminate the chance. Well trained, skillful and conservative pilot has much better odds of making it to retirement than marginally competent risk taker, yet it is possible that regular minima-buster enjoys his pension while the once excellent pilot is pushing daisies, much to shock, horror and surprise of those folks thinking in absolute terms and unable to see the world is too complicated not to include some randomness. Dark and stormy night, with the body clocks of two pilots at 4 AM, with third not far from midnight did significantly increase the risk of accident but the question is: from which level? That's the matter of not just training but also a pilot selection, initial as well as ongoing during the course of the career.

I have the idea that the PM had a very good idea what was going on but for whatever reason he was content to watch as the pilot flying manoeuvered both of them to their deaths. + 100's of others of course.Perish the thought, it is completely unrealistic to expect any human being to be allowed to be meekly taken to slaughter, especially as means to prevent it were at hand.

With 2900+ hrs TT and 807hrs in the A340/A330, (216hr on type), the PF almost certainly will not have experienced a significant failure with full application of adrenaline. Many will go an entire career without it, so highly-successful are the historical and present technological solutions to the safety of flight.Exactly. That's how many a flying ignorant has a successful career and some 10 000+ greybeards die after making a beginner's mistake.

We cannot give a course in "More Experience".Nor we should. What we need is more knowledge and better psychological selection. IIRC tolerance to the presence of danger without actively seeking it is the most sought after trait in any pilot.

Any pilot needs to be aware of all the factors that might limit his/her performance and how to mitigate them as much as possible. Indeed, but the problem is how does the affected one recognizes that he is affected? I'm exaggerating, but it is not entirely different to Raptor pilots suffering from hypoxia having to remember where the ring that activates the seat oxygen bottle is.

The newer pilots have few opportunities to hand fly their aircraft and operate mostly supervising the navigation computers of their aircraft and communicating with ATC, the second and third legs of the Aviate, Navigate, Communicate priority mandate. Why should they be comfortable stepping into the Aviate role when situation or system failures demand it?Not entirely. I recently got the fellow that made it to Q400 with 170 hours total time and 50 hours later got his line release - perfectly legal. He flies very neatly, knows procedures, limitations and systems very well, is willing to learn but also quick to correct me when I get it wrong. It is about actual hands-on practice but not as much as proper selection, proper training and, above all, enthusiasm for flying. DP Davies has it right.

There are far more newbies doing the job right than wrong, but the situations when they helped turn occurrence to non-event make it only to internal safety bulletins and are not discussed on PPRuNE. Unlike AF447.

We are all partisans. Being partisan is not bad by itself. Being partisan fighting for own prejudices, ideology and agenda, is.

If this phenomenon isn’t understood for whatit is, both politics and the law will continue the trend to find out who to blame and then crucify individuals at the pointy end. Correct. Bill Watterson neatly summed up that attitude:

http://cdn.svcs.c2.uclick.com/c2/28141d5022b2012f2fca00163e41dd5b

[jcjeant]

Hi,

Clandestino
Perish the thought, it is completely unrealistic to expect any human being to be allowed to be meekly taken to slaughter, especially as means to prevent it were at hand.This is not a general truth
The ancient and contemporary history of the world has shown several times the opposite
Check also the extreme ...
Panurge - Wikipedia, the free encyclopedia (http://en.wikipedia.org/wiki/Panurge)

[PJ2]

Lyman;
PJ2. Thank you, my friend, it is most welcome to find common ground.
We find common ground in your views,
Balance.

Equilibrium is the enemy of the entrepreneur, and in service to his own, and the culture of his clients and investors, the goals are set.

Action impels interest. Interest compels venture. Success breeds competition, and great success breeds ruinous competition. In the ashes of the ruins of failed schemes, survivors merge, freeze out competition, create their own credo and tacit co-operation, to create a stasis. Unsatisfying and not profitable, the goal shifts from value and service to survival, and it is these instincts that create danger. Success long gone, survival makes animals of men, and liars of the shepherds.

BEA will do nothing out of the ordinary, save to "maintain the status quo"

The document will be pure joy to dissect. In its language will be the compromise discussion of what I have just written. The industry is failing.

White knuckles used to have no basis in reality...
...which, rather poetically I think, states very well the blunt realities of the present economic crisis which, essentially though not exclusively through the absence of regulatory oversight, overtook the United States, not for the first time, in 2008 and is now overtaking Europe, (for different, though equally disastrous reasons).

The term "neoliberal (http://en.wikipedia.org/wiki/Neoliberalism)" as described in Wiki provides some understanding of why this notion of a political economy is important to understand. As grizz observed, this may have the appearance of thread-drift but it is absolutely central to most issues which have raised risk in aviation. It's just that most primary causes of aviation accidents, (mechanical/technical, weather, communications, ATC, navigation, mid-air) have been resolved and as those who do this work know, HF is now primary and far more complex and seemingly inexact, (and therefore difficult to hold the attention of CEOs focussed on marketing, costs and strategic planning while fiscally staying alive and keeping investors content).

Those whose job it is to formally brag about safety records have a pleasant task these days because of the present excellent record but an abiding graceful reserve in such pronouncements is missing - they read more like marketing assurances than quiet statements of confident fact. Those who actually do the work know that bragging about safety is the first mistake; - just do it, because bragging satisfies, and disarms caution.

My frustrations and even some overhanging anger over institutionalized irresponsibility are simple and certainly aren't unique: What do we do to in aviation to erect protective shields in the short term, and turn this around in the long term?

Believing its all going to h. in a handbasket is the wrong way to think about these trends - it isn't even close to falling apart but relief from the belief is no reason for comfort. The character of accidents has been changing - like Fukushima, Challenger/Columbia, perhaps like the RR engine explosion on QF32, we might first call these "economic accidents" because of their fundamentally systemic nature which have origins in not in technical principles but in economics where sometimes there is a scent of parsimony and greed. We know that where the principles of finance rule, the notion of "inconvenient information" has currency and that seems tolerable until accidents occur and the pilots, not the organization's CEO and senior executives, are the 50,000A fuse.

The psychology of "not listening", or of "dismissal" is an under-researched area. Why, when even outsiders would understand, are the cautions of such experts as named here, ignored in favour of finance? What makes those in charge believe they are acting in the best interests of their organization when they ignore the observations of experts. This is the story of Fukushima and we see the results today...an industry destroyed, not because it is unsafe but because it was rendered unsafe by a psychology of diffidence towards "nay-sayers" on the one hand and of "can-do" on the other. But for a protected diesel generator, there goes Japan. Why?

These are economic, social, psychological origins, not merely technical or mechanical; - analyzing a fatal aircraft accident in such terms has been the province of a few writers, (Perrow, Reason, Dekker, etc) but do the CEOs, the Boards, even the regulators comprehend the shift such that corporate and public governance behaviours change? I don't think so, because our society excuses corporate error (vice human error) and the law protects those not directly involved, preferring "simpler solutions".

None of this is new or particularly difficult to understand. What is difficult to understand is the unwillingness to address the worst outcomes of a neoliberal economy in high-risk enterprises. That's what Feynman meant when he said politics can't fool nature*, (but we can add, politics fools us...all the time!).

*For a successful technology, reality must take precedence over public relations, for nature cannot be fooled.

Rogers' Commission Report into the Challenger Crash (http://en.wikipedia.org/wiki/Space_Shuttle_Challenger) Appendix F - Personal Observations on Reliability of Shuttle (http://history.nasa.gov/rogersrep/v2appf.htm) (June 1986) Full Report (http://history.nasa.gov/rogersrep/genindex.htm)

[RetiredF4]

Quote RF4:
It´s not a question to stay inside the envelope, it´s a question how to do that

Quote Clandestino
Tens of thousands pilots do it every day. Staying inside envelope we call "flying", excursions are called "falling".

Quote:
Originally Posted by Retired F4
You sure did notice, that we are discussing the "falling" here in this thread.

Clandestino
So underneath all this talk about FBW modes, alerting systems, flightdeck ergonomics, way we did it on tactical fighters, French politics and spectacularly flawed hypotheses leading to absurd conclusions there is actually discussion about "the falling"? Forgive me for not having the patience to dig it out under all the rubble and being left with the impression "the falling" is the elephant in the room of this thread.

Forgive me my ignorance, it was yourself, who put the discussion back to this simple term. Or is it again a case of unlucky selective quoting (for what reason)?

I`m lost comletely there what you want to tell me.

Most everything of the rest of your elaborate post is pretty much spot on, and the final report will hopefully shed some light on some points discussed here.

[DozyWannabe]

Just a quick de-lurk to say that after eight threads and all that quibbling, I think Clandestino and PJ2 just nailed it.

Perish the thought, it is completely unrealistic to expect any human being to be allowed to be meekly taken to slaughter, especially as means to prevent it were at hand.

I've had "This can't be happening..." reactions to traumatic events that lasted far longer than they had between the onset of UAS and impact with the sea. I'm sure that's what you were getting at, though. Good work you guys! :ok:

[Lonewolf_50]

Clandestino: minor point, but I was not just referring to smootheness on the sidestick. Scan and knowing what procedures to apply are better improved by repetition, eh? ;)

[Lyman]

fmpov, that won't hold water. Unless PNF has death wish, he is acting quite satisfied that although not to his "liking", PF is sufficiently aviating that no takeover is required, and he'll "wait" til the Captain returns to sort out the loss of speeds.

Clandestino and Dozy are banking heavily on two pilots completely losing the ship to Stall, with nary a whimper. I don't believe it. To this day, I remain convinced something is missing from the explanation. Or something is missing from what we know. Or something important was missing from the displays, sufficient to fool these two into jeopardy.

Clearly, from the other thread, altitude awareness has fallen away before, I am aware of that.

[Jazz Hands]

Funny how this industry likes to bring up the "Swiss cheese" model after an accident, but also feels it's justified in blaming a particular slice.

[Lyman]

The Swiss cheese thing is a device, and in a way, deceptive. Why? As you say, it accommodates both poles, hence can be utilized by all, and suffers thereby...

Spread the responsibility? Whose slice is being gored? Your slice is obviously larger than my slice, etc. it is a follow on to a valid perspective, the "cascade".

It is a discussion shortener, a ruse.

There is a beginning, the technical term is "procuring cause", without which the crash cannot happen: the goose who turns left instead of staying straight, into the inlet, the lightning strike that chooses the antenna instead of the Radome, and the H kind, the vent that lines up with fuel port, the skin that isn't thick enough to last through dozens of pressure cycles, the Captain who rolls down a blind runway into the nose of an opposing a/c, because he is full of himself instead of caution, etc.....

Let me offer a procuring cause for 447.

At the moment of PF taking manual control, what did he see or sense that made him start the climb.... Postulates? Nothing, he just screwed up? His FD showed low, and rolled off right? He hadn't heard the Stall warn yet, so we can eliminate a rote response to approach to Stall, etc.....etc....

A metaphor, and subject to the observation of the perceiver.....

[Peter H]

Please forgive a non-pilot commenting on pilot related matters, but there do seem to be s/w and human-machine-interface issues involved.

Current “fault-tolerant” systems work splendidly for the infrequent failures they are designed for, but do not handle "simultaneous" failures adequately.
This is highlighted by the response to the near-simultaneous common-mode pitot failures on AF447. Which lead to the scenario something like:
- “simultaneous” pitot failures
- erroneous "as-designed" decision by a “fault tolerant” system
- “as designed” behaviour by other plane systems ultimately resulting in a computer-assisted snafu.
- the auto-pilot drops out and the unsuspecting crew are abruptly left holding an ill-defined hot potato.
- the [startled?] crew fail to rise to the occasion (for whatever reason or combination of reasons).
- various loud warnings are given
- loud warnings largely ignored/unnoticed, although the stall warning was terminated prematurely in what looks like a s/w "feature" (as-designed but surely not as intended)

How much better if the crew could be warned in a more timely fashion, and when they were in a calmer frame of mind?.

Suggestion
In addition to the current s/w behavior, when the s/w identifies divergent sensor readings it informs the pilots. When the s/w believes that the situation is
resolved it again informs the pilots (e.g. divergence ended or sensor retired).

AF477 case
The [relaxed?] pilots are told "airspeed sensors diverging" some time before any problem occurs (10s of seconds?). Hopefully they use the information
to alert themselves and catch up with the plane. In particular, to look and think about speed-related issues (and AoA).

Sometime later they are told "retiring airspeed sensor X".

Hopefully, when the sh*t eventually hit the fan, they would be more prepared for the situation, and already primed to consider stall and UAS.

The downside
The obvious questions are: how often would false warnings occur, and just how disruptive would they be.

Any thoughts?

Regards, Peter

PS Presumably pitot tubes may momentarily flood in very bad weather, and the system is designed to cater for this. I'm assuming that soft
pitot outages are filtered out by time-averaging techniques, then candidate hard outages are evaluated by a fairly slow comparison process,
which is intended to give any transient behaviour time to dissipate.

[Lyman]

Peter

Three identical probes. If there had been only one, the crash would not have happened. I can prove it..... Can you?

[HazelNuts39]

At the moment of PF taking manual control, (...) His FD showed low, and rolled off right? His FD was not available.

[Lyman]

ADI Nose Down. It was. Saving time, what is your answer? Did he simply pull back?

[HazelNuts39]

Yes, he did pull back, intentionally or not, we don't know:
2 h 10 min 07: The copilot sidestick is positioned: - nose-up between neutral and ¾ of the stop position; VS and VSsel are both zero.
2 h 10 min 08: The FD 1 and 2 become unavailable.
2 h 10 min 17:The FD 1 and 2 become available again; the active modes are HDG/ALT CRZ*. VS is then 4000 fpm.

[Lyman]

Nit pick, sorry

His FD went South concurrently? Does it matter? He had two options, at least re cues..... At 4000fpm and 2:10:17, what was elevator and G? Rule out chasing the cue? What was his altitude? He needs all three under certain circumstances to suss level, imho.....

Peter H? Chime in sport. Hint: The arrangement, type, and performance of Thales, were adequate, but not in conjunction with two others.

The Software was fatal, and unless changed, continues to threaten current flights of this type......

The two are related, but not fatally....

[infrequentflyer789]

Clandestino and Dozy are banking heavily on two pilots completely losing the ship to Stall, with nary a whimper. I don't believe it.

Whimpering there was ("we're going to crash" etc.), recognition there was not.

This shouldn't be hard to believe - this crew have plenty of company in that. It's not a new phenomena (e.g. BEA 548 back in 72) and nor is it an old one that's gone away (Colgan, Ethiopian...).

[Lyman]

Whimpering there was ("we're going to crash" etc.), recognition there was not.


After the Stall, and not wrong..... No whimper, that....

[Peter H]

Lyman Three identical probes. If there had been only one, the crash would not have happened. I can prove it..... Can you?

Great, what looks like a trick question from a domain expert.

I wouldn't dream of trying to address such an ill-posed question in an problem area I am so unfamiliar with.

Yes, I would be interested in hearing your take on the behaviour of an a/b modified [how?] to use a single a/s probe, when the probe gives
erroneously low readings for an extended period of time. And why it would differ so significantly from that of AF447.

[Lyman]

The Achilles Heel is Ice, to which all three are equally vulnerable, so using more than one is not only expensive, it's dangerous. Why? Because to reject one and then look at another is prolonging the loss of reads, by definition. Placing them on strategic points on the nose is meaningless. Turbulence is not an issue, they are not designed to be resistant or sensitive, in a functional way. The only solution is to use one, or another or two of different manufacture. That may mitigate the vulnerability, so why just one PITOT at all?

. The siren song is "redundance". "Simultaneous" failure is not unexpected, it is PREDICTED, which leads us to the fatal programming. The computer is programmed to rely on the possibility of a combination of probes being reliable, should one become an "outlier". So it reads and computes.....GARBAGE.

By definition, if not by trial or test...All the while, the a/p soldiers on, the pilots are unaware, and unprimed for a worsening situation whilst the computer hogs precious time and calm from the crew....

So for the false security of "redundance" the solution is anomalous design. Sensing systems that are different in approach design, and isolated from the problems of the other, by design, raising the reliability many fold, and eliminating parallel failure of identical sytems. With three same, Each combination of the six available to the computer is no more reliable than the other, in the midst of fail.

What to do? If the a/s is not consistent with other systems performance (and comparing them is not easy, but certainly possible), REJECT IT> ALL OF IT, INSTANTLY.......Trying to hang on to a failing system is ignorant, imo. And I have shown how if one fails, the others will, don't pretend they are different, and can somehow be reliable when they won't.

PJ2 has me convinced that UAS is not a serious problem and I believe....
But it is potentially fatal when it is treated as an emergency first by the flight computers, and then by giving it to to the crew...with controls alterations, etc.

At the first suspicion, reject the air system.....And keep the aircraft in NORMAL LAW, Don't make a mountain out of the molehill. A/P quits, the pilot flies Pitch and POWER, and soon, the AD returns. Or, with anomalous design, use it as with the Thales, as a dependable grouping, not a triple failure...

An excellent time for the crew to demonstrate proficiency in what we are told is a non-event. That will make Machinbird happy, because he is right, some real time challenge is what is indicated to bring the proficiency up a notch.

alternate Law? for UAS? Why? The builders and owners don't trust the pilots anyway, why make it harder on them? Just so when the a/c STALLS< it can be reported it was not in NORMAL LAW when it STALLED? If the protections are hot S... why not leave them in, lewt them earn their keep.

[Old Carthusian]

PJ2
The example of Fukushima is an interesting one and here in Japan the revelations are so enormous that they would take your breath away. The level of incompetence, nepotism and sheer mendacity is just staggering and the organisation seems to have learned nothing. It is also endemic throughout the whole power industry. How is this relevant to AF447? I do believe it ties in with what I have been saying about corrupt cultures - it is not just the drive to save money but that the organisational culture is fundamentally skewed. Lyman's comment about on the line is also very relevant. It is up to senior pilots to set the examples for others to follow. If the exemplars are professional and ready to help then the line pilots will mostly follow that lead. There also needs to be a certain level of ruthlessness so that sub-standard or pilots with under developed skills are not allowed to fly. This I believe very much links in with the cost saving ethos you identify. It is cheaper to allow them to continue flying than to correct the problems or remove them from danger.

[alf5071h]

Old Carthusian, et al, “How is this relevant to AF447?”
All that has been said or might be said about AF 447 or Fukushima, is in hindsight.
Are we really able to understand the situation as these people did at the time of their assessment and decisions?
If we are, then we must carry equal responsibility for not acting to prevent such disasters. No, at best we might say that our judgement was flawed, or more accurately that we lacked foresight.

Creating Foresight. (http://csel.eng.ohio-state.edu/woods/space/Create%20foresight%20Col-draft.pdf)
.

[Lyman]

I think it at times unfortunate that we humans have such an obsession with nomenclature, and identification. There is almost always a drive to synthesize a corporate culture that is monolithic, and a follow on to a former monolithic. This spills into the disciplines, and creates an inevitable conflict.

With great respect, it is at times also risky to create a new paradigm reliant on the creators of the old one. What lasts, what is resilience anyway, but time tested procedure that evolves, some times in spite of design, not because of.

We have a cross cultural habit of injecting useless traditions and prejudices into the new age, We fear the future, whilst we address it.

The soft sciences are so vulnerable to abuse, but here, I think a time out from that prejudice is important. As I said prior, we can create an environment for ourselves that promotes the human failings that we cannot discard. The secret is not to fight them, for they are who we are. Acknowledge, and look in the place where the problem is. At a time when leadership is rare, we have educated too many to assume its role, to our great hazard.

We encourage "outside the box" thinking, innovation, and analysis by the wrong people.

I promise, of all the "New" proposals I have seen, (business), there is a fanfare for the new, the new analysis, the new method. At times, when stupid things happen; the truly inexplicable failure cuts our project off at the knees, it is a human failing that has made it possible.

A healthy industry is not adversarial, not fearful, not greedy. Its inner bonds are strong (resilient?), its employees are secure, and specialists supported, and respected. So long as people are involved, it is crucial to support them, for in supporting ones employees, one makes possible great things. One cannot betray the people, as one would desert a machine, to labor on in darkness and obscurity.

The problem is a lack of leadership. The old ones know what it is, they are here, they have experienced the camaraderie and loyalty that come from a workplace that is kind, explicit, and honest. Not a desperate, snappish, and distracted struggle.

I have a tape of Feynman's last lecture... It was sublime.

Lighten the load, get a grip, and patiently recast the mission in the midst of its prosecution, It is a people business. The technology, as we see, is here.

Lose the fear.

[mm43]

By accident I came across this page (http://www.ahrtp.com/RSS-JSfeeds/AF_447_pitot-static_hypercomplexity-5d.html) dedicated to the explaining the problems associated with the pitot, and in particular the AF447 problem. It didn't take long to realize that most of what is there had been contributed by posters on PPRuNE.

Have a look, and you might find something of interest, or something you wrote.:hmm:

[A33Zab]

Although not admitted by some, we all know upset was initiated by PF.
Besides the recommondations already published at the publication of IR#3 (AoA indication, FDR, Manual Alt Training) there were valid questions still to be answered:

Press conference, 29 July 2011 (http://www.bea.aero/fr/enquetes/vol.af.447/transcript29juillet2011.en.php)


Alain Bouillard – .......
To try to understand the pilots' actions I have decided to set up a human factors group that will study the behaviour and the actions of the pilot, containing specialists in ergonomics, cognitive sciences -- psychologists, and doctors specialised in aviation.
We are continuing to examine the pilots' seats to try to understand if the adjustment could have influenced their inputs on the sidesticks.
.......


IMO that could prove if it was (initially) unintended.....



Jean-Paul Troadec - ....
There are two themes which are, which we could describe as doubtless the most systemic.
That is to say that, we think it is necessary to examine the way in which flight safety is organised at Air France and the way in which the monitoring actions of the oversight authority are conducted.
.....


For the first issue AF recently introduced the GATEKEEPER (http://www.ainonline.com/node/102950) system.

The second part, I expect it is self-audit....which IMO is not 'healty' in aviation by definition.

[jcjeant]

mm43
By accident I came across this page (http://www.ahrtp.com/RSS-JSfeeds/AF_447_pitot-static_hypercomplexity-5d.html) dedicated to the explaining the problems
Very good !

[HazelNuts39]

A33Zab;

Thank you for the link to the text of BEA's Press Conference on 29 July 2011. I found this little tidbit interesting (my bold):

Alain Bouillard – No call was made for the unreliable airspeed procedure - unreliable IAS - which requires checking that the autopilot is OFF, that the auto-thrust is OFF, that the flight directors have been shut down, and that the pitch attitude for this procedure is 5 degrees and that engine thrust is on CLIMB.

[Lyman]

HazelNuts39

I am not sure your point. If it is to emphasize the lack of proper procedures, you have. Something is missing, and it is exquisitely salient. The speech is given after the passage of time. Without a deliberate attempt to frame his comments in the context of the pilots situation it is misleading, to say the least.

Naturally, I will claim it is deliberate. It is.

He uses terms not in existence at the time of the crash. His summary is selectively exclusive, and presumptuous. Human nature being what it is, virtually everyone reading his text will absorb it in ignorance of its subtle purpose.

There was discussion of Pitch and Altitude, and immediately. The determination of UAS was made after 447 was on the bottom, I propose the crew were unaware of it until seventeen seconds after its appearance, and longer than that after its actual start. This presently can not be discounted, and bias and passion do not count as evidence......

Everything that is officially released, including data favorable to the crew,
must be received with profound distaste, and without prior thought....Absorb it as if it is toxic, and deadly, not as the Press release that is intended...


imho.

Who has selectively analyzed the DFDR to exclude the excursions present prior to a/p loss were due turbulence, and not the autoflight reacting to bs data? If so, the PF's situation becomes a little more explicit? Yes or no, where is that in Boudain's/Bouilliard's text? Where is "Nine prior Unreliable SPEED events occurred in a cluster less than one year pre-event?" Does he present the record of PROBE problems? The poor record of compliance? The utter lack of training that would have made his comments moot? Hmmm........

lyman

"IMO that could prove if it was (initially) unintended"..... Thank you A33Zab.

Anyone else resent the attempt to be led around by the ear as an errant schoolboy, by those with an incredible financial investment in the outcome of this investigation?

"Internists know everything, and do nothing. Surgeons know nothing, and do everything. Pathologists know everything, and do everything, but too late."

William Nolen, MD

[HazelNuts39]

Lyman;

The point is that M. Bouillard is misreading the UAS procedure. He quotes a "Memory Item" that is not applicable at cruise altitude.

[Lyman]

My volatile and impatient bad, sir. My comments were directed at the propaganda nature of the text, and not directed at a motive of yours. Of everyone here, and I mean everyone, you are the most objective, imho.

lyman

A question. Your "Misreading a UAS procedure..." Wasn't UAS a term that happened along post wreck? That is what I meant by his bias in incorporating new data that the crew had no knowledge of. "Climb", as reported by Msr.B is a wild statement, and since his remarks were undoubtedly edited, proofread, and approved, isn't it a sample of the investigations bias, and even fecklessness?

rhetorical question, I wouldn'e have you compromse your position with an opinion :ok:

[Machinbird]

Lyman,
One profession that specializes in hindsight bias is the Law profession, particularly tort law.
I believe you have more than passing familiarity with that profession.:rolleyes:

I would like to also offer the observation that your posts are becoming more relevant. I only wish there were not so many of them.:{

[Lyman]

Mach

If I felt the discussion was more balanced, or at least objective (read anything by HazelNuts39) I would make an effort to reduce....

I also would like to hear more from you.

You climb, I descend, fair deal?

[CONF iture]

The point is that M. Bouillard is misreading the UAS procedure. He quotes a "Memory Item" that is not applicable at cruise altitude.
It is inexact to state so. At best, the UAS is VERY poorly written.
The way it is written, the MEMORY ITEMS are always applicable when the safe conduct of the flight is impacted.
In my book I don't know any situation when the safe conduct of a flight is NOT impacted. The altitude is far to be the only such factor.

Instead of :

If the safe conduct of the flight is impacted : MEMORY ITEMS

the procedure should state :

If below MSA : MEMORY ITEMS
If or when above MSA : Level off for troubleshooting


Let's see if the BEA will mentioned how poorly the UAS procedure is still designed ... ?

[jcjeant]

Hi,

The BEA will publish the Final Report of the safety investigation on Thursday, 5 July, 2012 and at the same time will hold a press briefing.
We know by the most official source (the BEA itself) that is that the report will be released on July 5
It is not pretentious to say that the BEA currently holds the final report (it would not advance any precise date if he still had to conduct more investigations)
It raises the question .. why wait until the date of July 5th!

[Lyman]

If the BEA preferred, they would not release any report. The report has no upside for them, it is duty only, and cannot be shrugged...

Once released, it is become legend, there is no return, jcj......

There are ulcers proceeding in the bellies of the staff.

imo.

[Shell Management]

If the BEA preferred, they would not release any report.

They have no choice. ICAO Annex 14 makes it mandatory.

[roulishollandais]

@mm43

Interesting link, but I don't like the site reference.
Thank you for information

[PJ2]

alf5071h;
Old Carthusian, et al, “How is this relevant to AF447?” All that has been said or might be said about AF 447 or Fukushima, is in hindsight.
A very interesting critique, alf5071h, thank you for this. Having read and enjoyed your many observations here and elsewhere I know that there is a depth of knowledge and experience behind these comments.

I believe there is something more subtle than is being expressed in terms of categorizing "all that is said" only as hindsight. My question is, how do we proceed if all is merely hindsight and if not, what determines the difference? The paper you cite helps answer this question - so does Starbuck and Farjoun's later book, (2005), Organization Beyond the Limit.
However, I do argue that in the case challenged, (Fukushima), foresight was indeed in place but was set aside.

It is well understood, as demonstrated in the public record, that the risks of tsunami to the Fukushima Daichi installation were clearly stated long before the tsunami, (NYT, 2012 (http://www.nytimes.com/2012/03/10/opinion/fukushima-could-have-been-prevented.html?_r=1)). Further, it is clear that statements of clear risk and potential outcomes, (meltdown) were completely ignored by Tepco and others including the Japanese government. The risks were clearly delineated beforehand and the ensuing disaster as a result of a separate catastrophic natural event was entirely predictable and preventable. Hindsight bias is different than a recounting of the available record.

Are we really able to understand the situation as these people did at the time of their assessment and decisions?
Well, in one sense no, never. We are not them, we were not there. Also, risky conclusions about how people behave can and do occur. As the paper you link to observes, even the CAIB attempted to avoid hindsight bias.
If we are, then we must carry equal responsibility for not acting to prevent such disasters. No, at best we might say that our judgement was flawed, or more accurately that we lacked foresight.

Foresight can arrive in a number of ways. The notions of possibilism are broached in Lee Clarke's two works, "Worst Cases" and "Mission Improbable". Possibilisitic thinking provides a context in which what is possible and not merely probable, may be discussed. In Fukushima, "what is possible" was dismissed as "improbable" and further consideration of "what is possible, (after a 9.0 earthquake and a tsunami had flooded the diesel generators)?" was deferred in favour of a probabalistic argument. Answering the question, "Why?" relies heavily on hindsight work and can be valid so long is not "after-casting" and that change based upon new knowledge results.

In this case foresight was not lacking, so was judgement flawed or was there "organizational structurally-induced inaction"; - were the actions of TEPCO closer to making management decisions rather than engineering safety decisions?Regardless, your observation is interesting and I think really worth discussing in depth as we near the next phase of the AF447 threads.

[Lyman]

Shell Management:

From lyman : If the BEA preferred, they would not release any report. The report has no upside for them, it is DUTY only, and cannot be shrugged...

So thanks for the addendum....

PJ2, alf....

Foresight was in place prior 447...It is always in place. Given time, I could likely find the joker who warned Boeing about skin fatigue, and the COMET, and Alaskan's screw jack crimes.... Failures of epic proportion virtually never occur in a vacuum of data, or spontaneously.

QF 32? Want to talk to the man who warned Rolls about harmonics? Who was the guy on the floor, or the office, who saw the problem with the certification of the Thales? The THS potential for mischief? The STALLWARN issue? The over loud warnng of overspeed v SW?

damning evidence of failure is the enemy, in a pre "event" setting. It's in the superb link alf provided. STUPID STUPID STUPID. With a large dose of DENIAL, starry eyed paydays, and continued peer centered esteem.....It gets out of control, then all one can do is wait for the inevitable, and hope someone else is on duty when it happens, or one is parted the company, and for mutually beneficial reasons, anonymity will prevail....

If things go on long enough prior to the disaster, it will present that Mother Nature is at fault, with her weather, or robust thermal challenge of re-entry on a partially naked aircraft.....WRONG.

447 has all the elements of the longed for genesis of a catharsis to be welcomed.
When the chrome wears thin, one cannot merely paint...

[Flyinheavy]

Thank you mm43 for the link.
I don't know why, but after reading I recalled the statement of an airline boss - not in SAmerica or Africa, but of an flag carrier in the middle of Europe - "Passengers are not willing anymore to pay a little extra for safety....".
That was twenty years ago.

@HazelNut39

.......is misreading the UAS procedure. He quotes a "Memory Item" that is not applicable at cruise altitude.Well, as far as I did understand the procedure, above FL100 the memory items call for 5°/Climb thrust.
I found it strange, but as I never have flown a bus, I asked some friends current on the A330 and they concurred, although confirming, that they'd rather stay with the attitude/N1 which had been before the event.
May be you can explain what you ment. Here's a link to the procedure:

UAS.png - 4shared.com - photo sharing - download image (http://www.4shared.com/photo/uvH9vfRa/UAS)

[jcjeant]

Hi,

Flyinheavy
an airline boss - not in SAmerica or Africa, but of an flag carrier in the middle of Europe - "Passengers are not willing anymore to pay a little extra for safety....".Then the ...
It is indeed a great find ....
Passengers are now responsible for accidents because they do not want to pay for safety ...
These words of an airline boss gives an idea about idiots who occupy such positions
The airlines (or the market) make the price ... not the passengers ...

Well, as far as I did understand the procedure, above FL100 the memory items call for 5°/Climb thrust.
As far I know .. at this time (2007) it was not a "memory item"
The procedure in force at February 2007 shows that there are 2 steps
1 - Before the thrust reduction
TOGA/15 °
2 - After the thrust reduction above FL 100
CLB / 5 °

[Machinbird]

My French is terrible, but what does the short sentence at the top of the procedure posted by Flyinheavy say? It seems to indicate that if the conduct of the flight is endangered then.........
If that is anywhere close to the meaning, then at cruise FL, the procedure is NA(Not Applicable)

[Lyman]

"If conduct of the flight affects dangerously"

"SI CONDUITE DU VOL AFFECTE DANGEREUSEMENT"

NA: "NOT APPROVED" ?

[Old Carthusian]

Hindsight is not the issue. Just to reinforce what PJ2 wrote about Fukushima - warnings were plently and went as far back as the design of the original plant. They were constantly ignored through sheer laziness and attempts at cost cutting. Complacency and a risk management system based on odds also contributed. The whole system was corrupted including the regulatory authorities. When others refer to the supposed compromised nature of the BEA I smile ironically. If they knew what a compromised regulator is like they would pause before they wrote. The Japanese prime minister at the time of the disaster Naoto Kan had to order TEPCO to stay at the plant (TEPCO's plan was to withdraw all workers). The organisation was rotten and had been for years. Likewise, Air France developed a similar culture and this contributed to AF447. I do feel in a uncorrupted airline the PF would not have acted the way he did. Either he would have been sidelined or trained up to a suitable level. With over 30 UAS incidents happening before this one cannot say that we are shutting the stable door after the horse has bolted. One has to say that this is an organisational failure which could have been avoided.

[jcjeant]

Hi,

Machinbird
My French is terrible, but what does the short sentence at the top of the procedure posted by Flyinheavy say? It seems to indicate that if the conduct of the flight is endangered then.........
If that is anywhere close to the meaning, then at cruise FL, the procedure is NA. Pitot tubes blocked trigger an "unsafe condition"
So .. cause this unsafe condition ... "the conduct of the flight is endangered" IMHO

[Machinbird]

jcjeant
Pitot tubes blocked trigger an "unsafe condition"
So .. cause this unsafe condition ... "the conduct of the flight is endangered" IMHO It appears to be a misinterpretation IMHO. Anything that has the effect of bringing an an aircraft above its ceiling is potentially very hazardous. Meanwhile, the aircraft has been in a stable cruise without any obstacle clearance problems and has the potential to keep doing so, so why would any sane pilot want to disrupt that process just because some of the instruments are confused?

Rote application of an emergency procedure without understanding the appropriate circumstances has downed more than one aircraft.

[PJ2]

Flyinheavy;
Well, as far as I did understand the procedure, above FL100 the memory items call for 5°/Climb thrust.
I found it strange, but as I never have flown a bus, I asked some friends current on the A330 and they concurred, although confirming, that they'd rather stay with the attitude/N1 which had been before the event.

I wrote on July 30th, 2009 (http://www.pprune.org/tech-log/376433-af447-200.html#post5093749) that the correct response was to "do nothing". I don't claim any special prescience...it's just the logical thing to do when in cruise. When this entire matter was conflated in subsequent discussion, I argued that the memorized items were not only confusing but the entire drill and checklist were poorly written. The "above FL100" memorized item to pitch to 5deg and set CLB thrust was, in my view, intended to cater to high density altitude airfields, not cruise altitudes. But this is not clear in the drill.

There has been plenty of discussion on this item throughout these threads, and I suggest the use of mm43's excellent PPRuNe search tool (http://countjustonce.com/pprune/pprune-af447-all.html), to find these discussions.

The BEA press conference comment is, in my view, incorrect. While control would not be lost with an increase of pitch of 2.5deg to an attitude of 5deg, (because the pitch is already 2.5deg in cruise, roughly), the maneouvre does de-stabilize the aircraft when the aircraft is already stabilized in level flight with a good pitch attitude and power setting which were just fine moments before the UAS event. In fact, if one is not trained or accustomed to high altitude handling of a transport aircraft, one may be hunting a great deal with either a CC or an SS to maintain a pitch of 5deg. I just can't see, and never could see this memorized item making any sense whatsoever when in cruise flight.

jcjeant;
As far I know .. at this time (2007) it was not a "memory item"
The procedure in force at February 2007 shows that there are 2 steps
1 - Before the thrust reduction
TOGA/15 °
2 - After the thrust reduction above FL 100
CLB / 5 °

The items have been memory items July, 2006 according to the BEA IR#3 and the Airbus OLM training PDF on the UAS Abnormal cited below. The following is typical of the drill at the time:

http://www.smugmug.com/photos/i-GnmPntp/0/L/i-GnmPntp-L.jpg


There is the following PPT, from 2006, which illustrates that the need for clarifications to this drill and checklist may have been recognized as early as 2006:

http://www.iag-inc.com/premium/AirbusUnreliableSpeeds.pdf

In my view, the UAS drill and checklist extant at the time provided inappropriate "if-then" decision points for a crew faced with a loss of airspeed in cruise or the late climb/early descent phases of flight.

The primary decision-point is based upon whether the safety of the flight was impacted. That is an entirely subjective matter, as is evidenced by the differences in opinions offered on the matter by those who do this work.

In the above PPT presentation, it is stated that crews will be informed of the nature of this decision "in training", but as read by crews, the memorized items might, or might not be accomplished depending upon one's interpretation of the initial condition - the safety of the flight.

At cruise altitudes, I have argued that this was no emergency at all, it was an abnormal which required standard responses as trained, and which required no action other than to get out the QRH checklist for the pitch and power settings. Most here disagreed with this view, citing the "Above FL100 decision-point, but frankly there is no way that setting 5deg pitch is indicated in cruise.

Whether this PF intended to set 5deg or 15deg or something else cannot be factually determined at this time. But the airplane pitched up, and it was held there until the stall while both pilots accepted the trajectory, the pitch attitude and the loss of energy. We can only surmise why, and that, is, I think hindsight territory.

Here was my attempt at changing the UAS drill into something reasonable, last year sometime:

http://www.smugmug.com/photos/i-58PX24p/1/L/i-58PX24p-L.jpg

This "bifurcates" (makes a decision-point for the crew) the drill on altitude, not a subjective assessment in a moment of failure regarding the safety of the aircraft. Close to the ground, one sets memorized pitch and power. At higher altitudes in climb, cruise or descent, one sets QRH values while "doing nothing" to destabilize the airplane. That's what 30+ other crews actually did when faced with a UAS event.

Pitching up and changing power destabilizes a stable aircraft and, critically, takes it away from those conditions which had produced stable flight, into regimes which are far from stable flight, giving the crew an enormous situational awareness problem in determining the way back to stable flight, where they were in the first place. The "5deg pitch above FL100" is misleading and wrong but, read correctly, the drill does not require such a pitch attitude but instead requires the selection of GPS altitude on the GPS page of the FMGC and the stabilizing of the aircraft in level flight while the QRH is brought out by the other crew member for pitch and power settings.

[HazelNuts39]

Interim Report #1, page 70:
On the date of the accident, the operator’s procedures mention that the following actions must be carried out from memory by the crew when they have any doubt concerning the reliability of a speed indication and when control of the flight is “affected dangerously”:
(Memory items IAS DOUTEUSE)
If conduct of the flight does not seem to be affected dangerously, the crew must apply the UNRELIABLE SPEED INDICATION / ADR CHECK procedure (see appendix 9).Interim Report #2, page 53, study of 13 events of UAS:
With regard to crew reactions, the following points are notable:
 (...)
 Four crews did not identify an unreliable airspeed(12) situation (...)
For the cases studied, the recording of the flight parameters and the crew testimony do not suggest application of the memory items(13) in the unreliable airspeed procedure:
 (...)
 (...)
 There was no search for display of an attitude of 5°.
Is that intended as a 'slap on the wrist' or do they mean 'well done'?

[BOAC]

PJ - it certainly looks as you say that the QRH was not well written and that 'inclusion' of the 'Above MSA/Cct Alt' in the memory box 'immediate actions' would have been a better presentation (as 'appears' to have happened in the PDF), since 447 SHOULD have gone straight into the 'Level off for Troubleshooting' branch rather than zooming to the stars. I said a while back that 'going' to 5 degrees for the very short time before the a/c would be levelled off in the 'Above MSA' cruise situation would not really cause a problem, although your point about 'destabilisation' is true. However, leaving aside 'liability' on the QRH writers, it would not be unreasonable, surely, to expect crews of this level and a 'good' training dept to have ironed this out? It appears to come back to a general lack of awareness of what was happening, aka 'airmanship'.

It remains for me, I'm afraid, an inexplicable accident.

[PJ2]

HN39;

Re Post #1047 (http://www.pprune.org/tech-log/482356-af-447-thread-no-8-a-53.html#post7222400) , I'm not sure what the (translated) statement, "There was no search for display of an attitude of 5°" means but quite possibly it means, according to the available flight data from the flights studied, that no crews attempted to pitch the aircraft up to 5° but instead maintained the pitch attitude at the time of the failure.

Is that intended as a 'slap on the wrist' or do they mean 'well done'?
One way it could be meant is, "investigatively", as a statement of fact with no judgement as to value (right thing to do/wrong thing to do) either way. In the press briefing, the BEA has stated that the correct response is to execute the memory items, (ie, pitch the airplane to 5°), so it is difficult to know how this has been assessed in their Final Report.

In my view, even if the original memorized item of setting 5° turns out to be the intent of the decision-point of "Above FL100", what I (and crews who didn't respond to the UAS) believe to be an incorrect response is not in and of itself a problem, as BOAC has observed in past threads. A 5° pitch attitude isn't going to stall the airplane any time soon. (But the FCTM cautions the pilot to set level-flight pitch and power quickly because speed excursions can develop...I suspect that the caution was contemplating high-speed excursions ).

But it is the de-stabilization that could remove one quite quickly from his/her situational awareness in terms of stabilized, (high altitude, dark night, somewhat turbulent) flight and make it difficult to return to normal cruise settings for troubleshooting.

BOAC;

Regarding inexplicability of why this accident occurred, even if the pitch was mostly unintentional and a result of the PFs attempt to control a slight roll, recovering from the pitch-up would, and should be straightforward for a trained A330 pilot so yes, it is difficult to understand the continued pitch attitude especially after the stall warning.

[Lyman]

Hi PJ2...

Yours, above. recovering from the pitch-up would, and should be straightforward for a trained A330 pilot so yes, it is difficult to understand the continued pitch attitude especially after the stall warning.

IF PF had an insecure seat (due unbelted), would he at least at some point let go the stick, to get a visual if not a feel for the neutral point? I cannot remember if this has been discussed?

As to BEA intent ( "no effort was made to acquire 5 degrees..." ). It may be anticipatory, but a short analysis. No statement can be made re: a finding of fact w/o a foundation, even in a Presser, in my experience. IOW, they have not mentioned the A/C procedures, so they have supplied a dangling finding. It may be inadvertent, but if so, I doubt we will see a repetition. It is a guess, and an honest one; the possibility exists that BEA are throwing the airline a Bon, here. They have helped Airbus with the memo, and perhaps a slight push in the direction of isolating the crew for examination ( without prejudice ) such that there is a bit of pressure off AF, if only a little.

Who rights the OM? The Airline? Or the Airframer?

[PJ2]

Lyman;

The manufacturer writes the AOM but the airlines are free to modify according to their own requirements, obviously within reason. The modification I believe must be approved by the manufacturer and the country's regulator... someone?

Under the heading that anything is possible, positing an unbelted pilot remains in the "extremely unlikely" category in which everything is possible but without the capacity to enhance understanding.

If the PF had let go the stick the airplane likely would have gently, slowly recovered on its own, not, perhaps before impact but it may have silenced the stall warning, got the airspeed indicators working again, (because they had recovered by the time the airplane started down, post-apogee), and reduced confusion. It was the mostly-NU stick that held the airplane in the stall.

I view the BEA remark as nothing more than an investigative observation of fact.

[grity]

HN Yes, he did pull back, intentionally or not, we don't know:
2 h 10 min 07: The copilot sidestick is positioned: - nose-up between neutral and ¾ of the stop position; VS and VSsel are both zero.
2 h 10 min 08: The FD 1 and 2 become unavailable.
2 h 10 min 17:The FD 1 and 2 become available again; the active modes are HDG/ALT CRZ*. VS is then 4000 fpm. HN wouled you look at the FD in this few seconds while controling the roll left right left...and simultaniusly hear/talk this text and have a look at the ecam messages .......???

I have the controls
Ignition start
“Stall, stall”
What is that?
SV : “Stall, S”
We haven’t got a good
…
We haven’t got a good
display…
We’ve lost the the the
speeds so… engine
thrust A T H R engine
lever thrust
… of speed

http://s14.directupload.net/images/120602/nigmtjel.gif

[HazelNuts39]

The modification I believe must be approved by the manufacturer and the country's regulator... someone?To my knowledge, the AOM is not formally approved. The official document is the Airplane Flight Manual (AFM), which is approved as part of the type certification. The airline submits the AOM to its regulatory authority, which either tacitly accepts it or requires changes, but does not issue a formal approval. The manufacturer does not formally approve the airline's AOM.

From FAA AC 25.1581-1 Airplane Flight Manual (http://FAA%20AC%2025.1581-1%20Airplane%20Flight%20Manual):
3. Definitions
a. Airplane Flight Manual (AFM). An FAA-approved document that contains information (operating limitations, operating procedures, performance information, etc.) necessary to operate the airplane at the level of safety established by the airplane's certification basis.
b. Flightcrew Operating Manual (FCOM). A document developed by a manufacturer that describes, in detail, the characteristics and operation of the airplane or its systems.
c. (etc.)

[PJ2]

Thanks, HN39...wasn't quite sure. The country's regulator approves of the AOM though, is that correct?

[HazelNuts39]

PJ2;

There may be differences from country to country as to how airlines are supervised. To my knowledge the FAA Flight Standards Service does not formally approve operator's AOM's. But I must admit that I'm more familiar with the airworthiness branch.

[HazelNuts39]

HN wouled you look at the FD in this few seconds while controling the roll left right left...and simultaniusly hear/talk this text and have a look at the ecam messages .......???No I wouldn't, but then I'm not a pilot, and anyway the FD disappeared. Isn't it the PNF's task to deal with the ECAM?

[jcjeant]

Hi,

PJ2
If the PF had let go the stick the airplane likely would have gently,Methink if the PF let go the stick (auto reposition in neutral position) this will not help as the commands (mobile surfaces) will stay in the position they were set (climb .. THS climb .. etc..) and the aircraft will eventually stall
Push on the stick is necessary to move again the mobile surfaces for stop (or reduce) the climb or for go down

[Lyman]

jcjeant

If he is letting go the stick......

I think the mechanicals are split, the ailerons and spoilers would nest at neutral, because they are in Direct, Non? In Pitch, the airplane will keep climbing, (and climbing more and more steeply), it doesn't matter the stick in pitch, alright? And no way is there to know what the stick inputs produce, when in Pitch Mayonnaise, is that right?

[PJ2]

jcjeant;

Yes, the pitch change towards ND from 15deg NU would not be brisk, that's for sure, but with no Nose-Up input, the nose itself would slowly, (languidly) drop, probably not very far but it wouldn't be in positive territory, (I recognize that you are including the THS 13.6deg NU position as having an effect - I leave that to the aeronautical engineer people).

Also, I'm considering that "letting go" would not be a sustained response (I would hope!), but a momentary action if indeed he had to re-establish "neutral". But in fact, the neutral position of the stick is abundantly felt and is not at all a problem to place, so practically speaking, the entire scenario posited, (unbelted, finding neutral on the stick) is not plausible.

HN39, thank you. I'm likely a bit provincial in my awareness of these things!

[Lyman]

I do apologize for leaving out a few words. I know that sounds amazing, but,

Unbelted: to include, 'improperly', and 'loosely'.

Neutral stick. A poor attempt at irony. He had no chance to pause, he was very busy with ROLL. My subtlety or lack thereof had to do with him attempting to acclimate to a stick that had gone schizophrenic, touchy in Roll, and by comparison lethargic in PITCH. To accomodate and thereby coordinate control inputs must have been annoying, if not downright dangerous.....

Imho

[Lyman]

the Final has been translated into Portuguese, and shipped to Brasil. Parts have leaked, I am on the first page, so far nothing new. It can be found on another wewbsite....

[jcjeant]

Hi,

Oglobo
Voo AF 447: relatório aponta falha humana - O Globo (http://oglobo.globo.com/rio/voo-af-447-relatorio-aponta-falha-humana-5105646)
G1 - Brasil recebe relatório final sobre a queda do AF 447; saiba detalhes - notícias em Acidente do Voo AF 447 (http://g1.globo.com/Acidente-do-Voo-AF-447/noticia/2012/06/brasil-recebe-relatorio-final-sobre-queda-do-af-447-saiba-detalhes.html)
Research data confronted the black boxes with actions and answers the cabin of the aircraft and point to the design of the cockpit, the operator of the Airbus and the lack of proper training are among the main conditions for the pilots did not understand why the plane went downIte Missa Est

[Old Carthusian]

Lyman
If we do indeed assume that the PF was 'unbelted' a simple statement to his colleague - 'You have the controls' would be enough. He could then deal with whatever issues he had and retake control at a later stage. Once again CRM would seem to be lacking but even so there is no evidence of this set of circumstances.

[jcjeant]

Lyman
I am on the first page, so far nothing new.What could there be any new ?
Comments on human factors .. results of the special investigation panel of BEA?
This can be as imprecise literature
When a person (eg a criminal) is reviewed by a group of psychiatrists .. some will declared it insane and the others just said he is normal :rolleyes:
I don't wait many interesting news in the final report ... all was already in the interim report N°3
Maybe few new recommendations ....

[Lyman]

OC You missed my addend : Unbelted: to include, 'improperly', and 'loosely'.


Jcj. I don't wait many interesting news in the final report ... all was already in the interim report N°3

I disagree. There has been time to research thousands of pieces of evidence, interviews, and to experiment with new experts, and engage new disciplines. I think it will be quite something. I also think we will see some excellent results.

Thanks

[HazelNuts39]

There has been time to research thousands of pieces of evidence, interviews, and to experiment with new experts, and engage new disciplines.No doubt that has been done. But it is possible that all that effort has not produced new facts or insights, other than dotting a few i's and crossing some t's. IMHO the brasilian newspaper article could have been written from IR#3.

[Lyman]

Or perhaps from PPRuNe.

[Flyinheavy]

"A disposição de informações no painel e o design da cabine da aeronave foram fatores que contribuíram para dificultar que a tripulação identificasse a ação errada do copiloto menos experiente ""The display of informations at the panel and the design of the aircraft's cockpit were factors that contributed in hindering the crew to identify the wrong actions of the less experienced copilot"

If this is really written in the final report, then one could read between the lines, that those who criticized the SS layout sound more credible now, even in the eyes of BEA.
Just how I see it.

@PJ2

I definitely share your view on applying the UAS procedure at high altitudes. Just wanted to show the abnormal procedure used at time of the accident and that Mr. Bouillard obviousely referred to it.

IMHO let alone the lacking airmanship and CRM, I find it very strange that after some 30 incidents with those pitots there had been no real reaction in creating procedures a bit more refined and training of high altitude loss of airspeed.
As to lacking airmanship, in computerized planes, with training reduced to the absolute minimum (because the plane will take care of the limits, dosn't it?..:suspect:) how could young pilots gain this airmanship when they touch the SS only a couple of minutes every month and flew only a minimum on classic aircraft before taking the right frontseat of a bus?

[Lyman]

It is not particularly world shattering for the BEA to highlight the stick placement, if indeed, that is what they did. It is obvious without their affirmation. Hamburg again comes to mind.

As designed, and built, the SS stands on its own, there is not wiggle room for the decision. The team missed nothing, and assented to the layout warts and all.

For the third time I will point out the possibilities for ultimate single pilot carriage is obvious. You think the designers would leap without some sort of raison d'être for such a novel rig?

Should there be proof of mistake, and unplanned for possibility, the SS is single pilot in action, de Facto. Anyways.....

Once the ship lost her a/p, and her speeds reads, in the additional absence of CRM, she was functionally single pilot.......

I reject any "but a yoke system...." etc. In the Bus cockpit, the deck is stacked from the gitgo..... "I have been pulling up for some time...." No problem. QUE?

A Fix? Perhaps fisheye blind spot mirrors..... Next to the new Video Recording System?

[roulishollandais]

Hi Maching Bird,

My French is terrible, but what does the short sentence at the top of the procedure posted by Flyinheavy say? It seems to indicate that if the conduct of the flight is endangered then.........
If that is anywhere close to the meaning, then at cruise FL, the procedure is NA(Not Applicable)


No problem with your French, your traduction is perfect... Better than my English... :)

But there is no "N/A" in the French UAS procedure, so don't worry ! :O

The original French text in BEA#3 p.61 is :

SI CONDUITE DU VOL AFFECTEE DANGEREUSEMENT le CDB annonce "IAS DOUTEUSE" - effectuer les actions immédiates suivantes :
.
.
.


The three problems I see with that text are :
1. The CDB (the Captain, not BONIN) has to decide and announce
2. If the CDB judges that the flight is not endangered, nobody advertises "IAS DOUTEUSE" (UAS)
3. Is altitude cause of possible endangering associated with UAS ?


@jcjeant
Thank you for Oglobo ref : The Brazilian are always the first in the AF447 story !

[Organfreak]

@Flyinheavy:
If this is really written in the final report, then one could read between the lines, that those who criticized the SS layout sound more credible now, even in the eyes of BEA.

Indeed. IMHO, that would be great. The key words are your beginning ones-- for information of this type, source is everything. This is an unknown source with absolutely no bonafides. We really don't know what the source is or where it came from. Tempting as it may be to draw conclusions, I'm taking this "report" with less than a grain of salt.

Let's take a month off and wait. (For Thread #s 9, 10, 11, etc.) :rolleyes:

[Lyman]

Orgnfrek....

Less than a grain? Here, my shaker, you'll need more.

[roulishollandais]

O Globo shows once more it is one of the greatest media in the world. They already were the first to publish the Acars. With AF447 we have to thank and congratulate our Brazilian friends for showing a modern conception of aviation, and in sharing air safety informations.:rolleyes:

The only better media, were Ppruner, indeed ! ;)

As a French retired pilot I am sure that you all, not French, have helped seriously France to overcome pressures over French Aerospace.

Thank you ! :)

[RetiredF4]

A ggogle translation of this website:

Brasilian military (http://www.fab.mil.br/portal/capa/index.php?datan=02/06/2012&page=mostra_notimpol)


Brazil receives final report on the fall of 447

France officially release the document on July 5. Tragedy that killed 228 people completed three years on Friday

Tahiane Stochero

The pilots of flight 447 did not understand the time the plane lost support after a procedure wrong copilot's newest and this led to the crash, which killed 228 people on 1 June 2009. In the final seconds, they tried to prevent the accident, but the aircraft was already so low speed reversing the decline of the Airbus A-330 Air France - which had departed from Rio de Janeiro and went towards Paris - the Atlantic Ocean, three years ago, it was virtually impossible . The provision of information on the panel and the design of the cabin of the aircraft were factors that contributed to hinder the crew identified the wrong action of the less experienced co-pilot - who was with the commands - and also that the plane was falling because he has lost support.



These records included in the final report that the BEA (Bureau of Investigations and Analysis, in charge of the investigation) says it will unveil on July 5. The document has been received from Brazil, USA and Germany to the final considerations, as found the G1 . According to international law, the Chicago Convention, countries have 60 days to forward its position. BEA can not change the text based on the weights made, but they should be included in the final report.

Research data confronted the black boxes with actions and answers the cabin of the aircraft and point to the design of the cab, the operator of the Airbus and the lack of proper training are among the main conditions for the pilots did not understand why the plane went down. Three other preliminary reports were produced by the French organ. The latter already had the information from black boxes and copilot reported that the youngest was in command of the aircraft. The commander had left the post to go to sleep just before entering into a storm, without a clear division of tasks between the co-pilot.

When passing the storm, low external temperature sensors pitot freeze and block the speed measurement. Without accurate information, the Airbus out of the autopilot. The copilot assumes newest commands, and an attitude that does not know how to explain, raises the nose of the aircraft, causing the stall alarm (loss of lift) double tap. With the procedure of climb, the plane loses speed even more and really start to lose support. The stall horn playing more than 70 times - some for nearly a minute uninterrupted. copilot The youngest, who is in command, it keeps climbing action, while the corrreto would play the nose of the plane down speed and retrieving support and prevent the accident. None of the pilots had received training in case of loss of support of Airbus in high altitude and speed without reliable information. The more experienced co-pilot comes to giving, at times, the order for his colleague to take the right attitude, but is not aware of the mistaken action of his companion, and this was hampered by a lack of information about the real situation in stall Airbus panel.

When called upon by more experienced co-pilot, the captain returns to the cabin about 3 minutes after the fall of the autopilot. He does not understand what occurs and does not take any action. Less than 1 minute later, the Airbus collides with water.
In no time, passengers were given notice of the problem. All 228 aboard died in the tragedy. Only 153 bodies were identified after a search.

Control System

BEA created a working group to try to understand the actions of the crew cabin and psychological factors - such as pressure, stress, work overload, or prior knowledge - interfered with the tragedy. But what the pilots thought at the time it is impossible to determine. One of the hypotheses are the changes made ​​during the flight control modes of "fly-by-wire" Airbus.
When the autopilot disconnected, the computer becomes "normal law" (so that it protects against the plane movements and avoid the wrong stall) for "alternate law" (with few protections on the actions of the pilot). There are two forms of "alternate law" - one with and one without protection stall.
When pitots computer froze and began to receive information from disparate speeds, the A330 went into "alternate law" unprotected stall. It is possible that the rookie driver did not understand some of the restrictions of the system and had never flown in this mode.
Check out 11 factors that led to the accident on 447 on 1 June 2009:

Flight control

Flight 447 departed from Rio International Airport, in Rio de Janeiro on the night of May 31. When flying over the region monitored by Cindacta of Recife, the controller makes contact with the flight crew believed to be another flight, also from Air France, which had left St. Paul at the same time. The commander realizes the error and warn.
Minutes later, the controller is a new radio frequency that the crew should use to contact with Senegal (the next area of radar coverage). The commander repeats the numbers (the action is called collation), but a return of 12 digits. The controller in Recife do not realize the error. Later, a Brazilian driver attempts to contact - unsuccessfully - three times with 447. The region is not covered by radar, the aircraft was not connected to a satellite system that would allow sending data.

Location and rescue

Air France was no delay in reporting the disappearance of the flight and to start the search. It also controls the airspace of Brazil and Senegal took to notice the disappearance of the Airbus A330.
Aircraft and ships from France, USA and Brazil have been moved to the area only during the day. According to the black box, the drop occurred at 2h14min28s GMT (23h14 in GMT). The first wreckage and bodies begin to be found almost a week later.

Storm (weather)

When the aircraft goes into the storm, the clouds a bit concerned about the pilots. They comment on the meteorological factors and had already faced similar situations and worse. The turbulence level increases slightly, but that's not enough to scare. The storm may have acted as a psychological factor, such as increased stress. And there was a failure in the analysis of weather conditions. The crew could have changed the route and diverted the storm, as other aircraft that have made ​​the same trip that night.

Pitot probes

In the passage above the storm, the outdoor temperature drops too and there is ice buildup on pitot probes, which ceased to have correct information about the speed. The system began to receive information three different speed, and the autopilot disconnected. Air France said at the time he was in the process of exchange of other probes that resist up to - 50 ° C. The manufacturer and the agencies that regulate civil aviation in Europe and Brazil could have required that the model only fly at high altitudes with pitot greater resistance.

Lack of understanding

Pilots do not understand what is happening, even with the stall horn playing 75 times. They also do not understand what information was correct. None of the pilots identified formalmanente stall the situation and none of the pilots mentions aloud the stall, which is standard procedure. The passengers received no warning.

Error procedure

When the autopilot disconnects, the youngest rider began to put the plane's nose upward, causing a stall situation. No one knows the reason which led him to make such a decision. The correct action would be to play the Airbus nose down to gain speed and recover support.
The BEA noted that "in less than a minute after turning off the autopilot, the plane leaves its field of flight as a result of the actions of pilot manual, mainly to raise the nose."

Management cabin

The failure of management control cabin (CRM as the acronym is known in the aviation community) is considered an important factor. The commander was rest and gave his place to the most novice copilot, while recommendations and clear division of tasks between the co-pilot. The less experienced co-pilot (Pierre-Cedric Bonin, 32, and 2936 hours of flight) takes over.
The more experienced co-pilot (David Robert, 37, and 6547 hours of flight) take long to realize that his partner was taking the wrong attitude. Just got in the last seconds before the Airbus colliding with water.
The preliminary report has already pointed out the need for a system with greater autonomy for the post of co-pilot, allowing a greater division of labor in the control of Airbus.
Automatism
There is no way of knowing what caused the less experienced co-pilot to commit the mistake and why the other two pilots did not understand the stall horn. One possibility is the control system of the Airbus (fly-by-wire). Pilots could be believing they were in a control mode - where the aircraft went in after the loss of information and the fall of the autopilot - he had protection for stall (loss of support). not known whether the pilots ignored the stall horn because they believed it was a spurious signal. Another issue is the lack of a visual indicator to pilots during the fall, the actual level of stall (the factor is called the incidence and activates the alarm loss of support).

Cabin Design

The position and design of the cabin may have impaired the most experienced driver to miss the wrong attitude of the beginner. The "control stick" (or "side stick" device similar to the video game controller used to send orders to the computer) is positioned below the side window next to the seat of each pilot. This position could disrupt one of the pilots to see the orders that the other is going to the aircraft. This observation, however, is relativized because the command appears on the control panel in front of the pilots when the order is given. Despite the low speed and the aircraft no longer flying, pilots, cabin, did not realize, nor had the view that this occurred.

Training

The pilots had not received training to deal with loss of control at high altitude and not on reversing situations stall at high altitude.

Stall

The loss of lift of the aircraft is the cause of decrease of A-330. The plane estolou and remained in this situation because of the wrong procedure of the pilot, according to BEA.
The final report will recommend improvements in the alarm system and the manner in which pilots can view directly on the panel the incidence of slope and position of the aircraft stall.

The G1 searched Air France, but until the publication of this article received no return. In a statement to the G1 , Airbus said that "the authorities investigating the accident did not identify any problems related to aircraft" and that "to date, no recommendations "related to the model. "The report of the BEA has not yet been published, so any mention in the press is mere speculation," says the manufacturer. About the functionality of the cabin, Airbus says it "has been used for decades and was designed with the drivers of companies Airlines and industry officials. " The construction adds that "the system of cockpit Airbus Fly-by-Wire is in operation since 1988 and already counts 143 million flight hours and 65 million flights today."

[Machinbird]

Should it be deemed necessary, it is very likely that an electronic backdrive of a not in use sidestick could be done within the space available. Of course, the interpreting software would need significant "adjustment" to the new circumstances.

From the dialog reported in interim report 3, it is clear to me that neither PF or PM's scans ever came up to speed, but instead got stuck staring at just a few parameters. The process of integrating the data into a full picture never actually happened.

IMHO, That is the root cause of this accident. Whatever PF was attempting to do with the aircraft, he did not integrate what effects his control inputs were having on his mental picture of what the aircraft was doing.

The only cure I know of for such a scan problem is hand flying---Lots of it! You could do it in the sim, but the natural fallout would be a much larger installed base of simulators to support the program.

Perhaps it is possible to develop a computer application that could be positioned in pilot briefing areas that would provide this refresher training, or within one's own laptop for practice as you felt the need.

However, I still look at all that cruise flying that is presently being given to Otto as the best, most realistic, cheapest, potential vehicle for training.

I am a firm believer in overtraining in such a critical skill as scan. For example, USN's theory on carrier landing practice was to do the first familiarization bounce pattern during the day, and then move all the remainder of the bounce periods into night work. For your edification, the night bounce was flown identically to the day pattern with a 600 foot downwind altitude. The bounce field was in an area with little ground lighting (until the housing moved in much later:mad:). This was a combination of instrument scan and visual scan to fly the pattern (which is about as demanding and realistic as you can get.) Each pass was graded by a qualified Landing Signals Officer, so there was no playing around. This instilled in all of us a virtually unbreakable scan.

It remains to be seen whether AF447 is indeed the canary in the coal mine for more LOC accidents of this type.

Note: I am using a definition of scan which includes developing a mental picture of what the aircraft is doing. I believe others are using this term as the process of just reading the indications on the instrument panel.

[wozzo]

When called upon by more experienced co-pilot, the captain returns to the cabin about 3 minutes after the fall of the autopilot. He does not understand what occurs and does not take any action. Less than 1 minute later, the Airbus collides with water.

Interim Report N°3:

AP disconnect: 2:10:05
Captain returns: 2:11:43 (roughly 1 and a half minutes)
End of recording: 2:14:28 (little less than 3 minutes)

[PJ2]

Machinbird;

If they're going to recommend an actual change in the SS installation, ( as opposed to merely commenting on it...the word "rationalized" is in the Google translation which I take to mean "mitigated" which I again take to mean "even though there may be a visibility matter which may have contributed to a loss of control, no recommendation to alter the design is made", or something like that), then, along with any backdrive solution, a display of the stick position is going to have to be available because it is not at all easy to judge how much stick deflection is being applied by the other pilot purely by looking at it. This is because, first, the stick movement is small compared to a CC, and second, from the other seat, it is difficult to judge where "neutral" is. Placing a neutral marker near the SS for either the fore-aft or sideways movements of the stick to be accurately judged is difficult given the placement of the stick and it's surrounding structure, and parallax would be an issue.

The same display that we see at takeoff is an obvious solution. Presentation would be slightly different than the takeoff one; (the symbol is not visible on landing). The iron-cross could be placed in a circle. It's position indicates stick position. Concentric markers can indicate degrees and that can even be displayed digitally in a small box which is "attached" to the SS symbol. That's one way to display it on the PFD.

Obviously it wouldn't be there during autoflight and choosing when and how to make the SS symbol available and where, during manual flight, would require thought about of the importance and therefore the attention-getting priority of the information. (I always found the amber Alternate Law symbols vague and not at all obvious, but then at the time, purely out of decades of habit we flew the airplane as though there were no protections. And we "looked through" the FDs because they were rudimentary and the raw horizon data was "real". The subtle psychological shift that has occurred in the "children of the computer age" who know nothing of airplanes before the kinds of autoflight solutions we have today perhaps requires that a clearer indication be available to the crew that the airplane is in Alternate Law even though it is annunciated on the ECAM and is a checklist item.)

There is an obvious drawback to any new display of information: It must compete for the pilots' attention and possible action and it must be standardized/trained/checked.

However, in this debate regarding back-driven sticks and more information regarding SS position, I think the solutions are not in this direction but in a philosophical shift in approaches to training. In some quarters, it is indeed occurring already as enlightened managers and perhaps the occasional CEO who read a lot more than balance sheets are beginning to comprehend that automation has its place and it is not as "the third pilot".

This shift in training priorities and focus is not something that individual pilots can do by themselves. This is not a home-study-course problem. This is a performance problem, and must be worked into recurrent simulator sessions, check flights and must have standards by which success or "drift into failure" can be measured.

The self-fulfilling actions of airlines which tighten hand-flying restrictions after an incident must be examined and changed, especially for long-haul transport crews. Yet airlines are extremely reluctant to "waste all that automation they paid for" and implore crews to keep the autoflight engaged until late in the approach, taking over about thirty seconds before touchdown. Because of RNP restrictions and complex SIDs and STAR Profiles, hand-flying is not only discouraged but in some cases prohibited by airline policies given the speed and altitude accuracies demanded by these navigation procedures.

AF has run a FOQA/FDA/FDM Program for decades. This kind of program can pinpoint very easily and quickly, degradations in such standards. One sees this in a number of ways, but the character and nature of the approach and landing phase is the best area to examine.

Sidney Dekker has just put out another great book entitled, "Drift into Failure". "Drift towards failure" is discussed in the Woods article to which alf5071h referred a few pages ago when referring to hindsight and hindsight bias. Dekker discusses hindsight and the phenomenon of hindsight bias. He discusses the "normalization of deviance", a notion and term which Vaughn created in her superb sociological study, "The Challenger Launch Decision - Risky Technology, Culture, and Deviance at NASA", (1996, University of Chicago). (Another superb work was hinted at by alf5071h in the same post, by Starbuck and Farjoun, (Organization at the Limit, 2005, Blackwell, in which the Woods article now appears).

Dekker also contributes a succinct understanding and measure, by which the phenomenon of hindsight bias is made visible in our thinking and discussions: He writes in "The Field Guide to Understanding Human Error", (2006, Ashgate), "What (you think) should have happened cannot explain people's behaviour."

How then, will the BEA Report address the issues made clear to us in the data and three years of discussion and examination?

[mm43]

PJ2, Machinbird

It will be of interest to note whether the BEA's Human Factors Group report is included in the Final as an Appendix in its entirety, or if the BEA chooses to selectively use its contents as a means of 'backing' the recommendations it (BEA) presents.

The issue of back-driving the SS will be contentious as demonstrated by content in these threads. So the SS position on the PFDs when the A/P disconnects seems the only option, though it will add to the 'scan clutter' and has received a number of vetoes in these threads.

All the other issues, including CRM, training and handling skills have been dissected in great detail here, and as far as I'm concerned the professional abilities of those involved in this accident leave a lot to be desired. Where the blame will be "sheeted home" will primarily be with the airline, though one has to ask, "What part did the Regulator have in this lackadaisical environment ?"

[alf5071h]

For those who have yet to believe … and might be able to learn … if only …
http://i48.tinypic.com/14d3woh.jpg
With apologies to Peter Nicholson. (http://nicholsoncartoons.com.au/wp-content/uploads/2011/02/2002-10-16-Bali-terror-predictable-unpredictable-530.jpg)

[Machinbird]

Dekker also contributes a succinct understanding and measure, by which the phenomenon of hindsight bias is made visible in our thinking and discussions: He writes in " http://images.ibsrv.net/ibsrv/res/src:www.pprune.org/get/images/misc/amazon_icon.gif (http://www.amazon.com/Field-Guide-Understanding-Human-Error/dp/0754648265/) The Field Guide to Understanding Human Error (http://www.amazon.com/Field-Guide-Understanding-Human-Error/dp/0754648265/)
", (2006, Ashgate), "What (you think) should have happened cannot explain people's behaviour."
Hi PJ2. I am assuming this statement was not directed at my previous posting but as a general caution to those who would analyze accidents. I have a copy of Mr. Dekker's field guide in my library. I have seen two accidents long ago that caused me to examine my thinking and I understand well how the cockpit view differs from the external view.

My conclusions with regard to AF447's crew's performance resulted from an analysis about what must happen for success, and then examining the record for evidence of these critical performance activities (and not finding them).

Dekker's new book "Drift into Failure" is more likely to be highly relevant to the underlying causes of the AF447 accident. What has me highly concerned is that the same causes are very likely to be found active in other airlines to varying degrees due to the similar operating environment. Guess I know where I should use that Amazon gift certificate I received awhile ago :}.

My statement with regard to backdriving the sidestick should be interpreted as meaning that I believe it is technologically practical to do so based on my slightly outdated understanding of automation devices. It should not be interpreted as a recommendation. I would only suggest it if it was practical to lay a hand on the second stick and perceive the other side's inputs effectively by tactile means. That may require some research.

The PFD is highly cluttered already, and I too question the effectiveness of changing the color of portions of the display to signify important changes in operating mode. A stressed pilot is very likely to miss that type of cue.

ALF, It is a pleasure to have your input again on this thread.

though one has to ask, "What part did the Regulator have in this lackadaisical environment ?" That I think we already know. They were a part of the "Drift into Failure". Where the blame lands is for the courts to decide. However, blame is not relevant to accident investigations in most cases.

[PJ2]

Machinbird;

Re, "Hi PJ2. I am assuming this statement was not directed at my previous posting but as a general caution to those who would analyze accidents."

You assume correctly, and my apologies!...not directed your way at all, (as I know you know your stuff), but placed as part of the discussion I wished to have on the topic so that others might take up the conversation as well. I think it is a very timely discussion, given that the report is on its way. The quote I used is exactly as it appears in Dekker's book, including the "(you think)" phrase, (Ch 5/pg39) and it was my unfortunate oversight that did not clarify the quote.
My conclusions with regard to AF447's crew's performance resulted from an analysis about what must happen for success, and then examining the record for evidence of these critical performance activities (and not finding them).
Precisely.

There is no hindsight in examining the record of what is. Hindsight bias is an interpretive gesture, not an investigative act.

Your comments on the SS were taken as intended - as entries into the dialogue and not as recommendations or even suggestions.
A stressed pilot is very likely to miss that type of cue.
Yes, we already know that it is possible for whatever reasons, to miss serious, emergency warnings designed to grab and focus attention. In my view I think this in itself is worth a full examination - why did this occur?

We know already that, first, comprehension through thorough training, and trust, which follows belief in the airplane and its systems and instrumentation, is paramount to safe flight. As many have said, we have here an accident like no other.

The record shows a lack of crew coordination and understanding of the airplane and of high altitude flight. Considering why, is an investigative act. I think the best example on record for highlighting this shift in thinking from thinking about how crews should behave to why they behaved the way they did, is still Diane Vaughn's book because she talks about her hindsight bias first and then shows how her persistent investigative work and open mind made such biases visible and provided the foundations for the shift in perception.
ALF, It is a pleasure to have your input again on this threadIndeed it is...also, great cartoon.

Quote:
Originally Posted by mm43
though one has to ask, "What part did the Regulator have in this lackadaisical environment ?"
That I think we already know. They were a part of the "Drift into Failure".
The following statement is a general observation and is NOT to be understood as referring specifically to any regulator or airline here. The statement carries no meaning other than what it says. That clear, I want to observe that we already know that too comfortable or cozy a relationship between regulator and private corporation is unhealthy for both, and also for the end-users of and in both organizations. It has occurred in the past and has resulted in incidents and accidents. The regulator must be free to enforce or support as necessary but to retain authority of standards. That was my initial reaction to SMS and as far as I'm concerned the jury is still out on the self-regulation of airline safety...another thread entirely.

[CONF iture]

The record shows a lack of crew coordination and understanding of the airplane and of high altitude flight.
No other tool that fully visible control columns can better enhance crew coordination - It is all about naturally sharing first hand information - A crew needs sharing, not hiding.

[HazelNuts39]

No other tool that fully visible control columns can better enhance crew coordinationIn the case of AF447, I believe a distinction should be made between phases 2 and 3. After the airplane stalled, seeing the control pulled to the back stop with the nose up might have helped to focus the PNF's awareness (and even more that of the captain) on the problem that the airplane was stalled. IMHO in phase 2 knowing the movements of the longitudinal control would not have added anything to the PNF's understanding of what was happening.

[Lyman]

from PJ2, quoting Machinbird

Quote:
My conclusions with regard to AF447's crew's performance resulted from an analysis about what must happen for success, and then examining the record for evidence of these critical performance activities (and not finding them).


from PJ2: "Precisely"

agreed.... That sustains a reasonable interpretation of a common metric, to wit:

"What did they know, and when did they know it." Which is a presumption requiring evidence to support, save for some linkage with actual commentary from the pilots....

To fine tune, "What was displayed, available; and what actions can be associated with its acquisition, comprehension, and 'action taken'.

So I will go out on a vulnerable scout, not all three pilots were untrained in probblematic high altitude flight, if we entertain that the two not "inputting" honestly were prevented due to poor design from sussing the control inputs of the PF.

alf, a question? Subject to humor, is hindsight bias a conclusion in itself subject to bias on the part of the judge?

The foresight discussion: "What did they know, and when did they know it"? Is susceptible to unprofessional critique, but I expect many in the Public will have all the bases covered.

I submit that this investigation has the potential, due new technology, to include widespread exposure. That will be good, and it will be bad...

Columbia, and Challenger before it, laid the groundwork for widespread exposure of the stupid things that are done by those previously protected by the culture from disclosure.

We will have to see how everyone reacts. The balance sheet will be written through time, but for me, the worn out buddy sytem and the conspiratorial secrecy that endangers the lives of the public is about to be tested, and there will be many things that are distasteful to know. The good, I believe, will far outweigh the dying rattle of a culture that may be held responsible for needless death, and that by greed.

[HazelNuts39]

http://i.imgur.com/LWce0.gif?1

[Lyman]

PJ2 says that neutral stick is easy to place, in the mind, by feel.... I believe.

So.... 1) The PF does not know where neutral is, or, 2) he does not know the NOSE position, or, 3) he thinks that minor corrections are needed with the stick back of neutral, similarly, when it is forward of neutral.

Would a Bus driver take the time to interpret for us the stick placements that killed them? Is it reasonable to comment on a partner's use of the Stick, or is it too 'personal'?

Another question that I think has not been addressed: Why is the pilot so stick busy? The aircraft is very large, very gentle in responses, and he looks like he flies a helicopter in a windstorm.....

[CONF iture]

IMHO in phase 2 knowing the movements of the longitudinal control would not have added anything to the PNF's understanding of what was happening.
At the very start of phase 2, the stick is already between neutral and 3/4 back. From my personal experience, I just cannot remember any control column 3/4 back at FL350, except maybe for an approach to STALL simulation ...
To witness such movement is simply shocking.

[Machinbird]

HN39 an excellent presentation of how the AF447 crew lost all their energy before the stall. Not as a concentrated pull up, but as an additive process with a nose up bias.

Another indication of a FUBAR scan.

[HazelNuts39]

Machinbird;

Thanks, I was having some trepidations about posting.

[Lyman]

Machinbird

"but as an additive process..." Could I ask for more? By additive, do you mean he piles on NU on NU? Increasing, without regard to result? You don't mean added to any process of a/c, eg THS? Or other action of which he was unaware?

Would you hazard a possible reason?

I ask because I find it impossible, given the evidence, that any second Pilot would allow the PF to eat paste whilst the a/c climbed as it did, according to the released evidence....

Consider this rhetorical if you like.

I think this "additive process" is in here somewhere.

[OK465]

With momentary audio stall warnings at 2:10:10 & 2:10:13, that graph itself would 'sell' me on an 'intrusive' PFD "PLI" for Alternate & Direct Law.

[grity]

LY 1) The PF does not know where neutral is, a brocken rod-spring in the SS was and is seldom, but not impossible to lose the neutral point

[PJ2]

HN39;

Agree with Machinbird's comments. Thank you for posting this.

The graph shows clearly, the "time-spent-in-NU-territory" of the control input, and the resultant pitch trend.

[PJ2]

Lyman;
Columbia, and Challenger before it, laid the groundwork for widespread exposure of the stupid things that are done by those previously protected by the culture from disclosure.

We will have to see how everyone reacts. The balance sheet will be written through time, but for me, the worn out buddy sytem and the conspiratorial secrecy that endangers the lives of the public is about to be tested, and there will be many things that are distasteful to know.
How do we know beforehand, that a culture is a buddy system and not an honest system? What are the metrics, beforehand? When do we know that people are "being protected" vice doing their job? How is "conspiratorial secrecy" recognized from "proprietary information" which, in a competitve political economy, is the lifeblood of all organizations? How do we parse and subsequently judge action in different discourses, the most well-known example being the "discussion" between Morton-Thiokol engineers (engineering discourse) and NASA managers at Houston (management/political/economic discourse), regarding the Challenger launch decision. Are the discourses "translatable" into a common language or do we have power politics as the arbiter?

[A33Zab]

a brocken rod-spring in the SS was and is seldom, but not impossible to lose the neutral point

implausible with dual cartridges:

http://i474.photobucket.com/albums/rr101/Zab999/ArtRod.jpg

[PJ2]

HN39, okay, thanks very much for the correction and the information. We let go of the stick in the sim exercise but that was in phase 1.

[Lyman]

PJ2.

How de we know beforehand? We don't, and that is the plan. Unless the domain is so witless or uncaring, no care is taken to protect eachother.

Oversight, Investigation, Audit, Inventory. These are costly, and so at the very least, profit deters their implementation. I was involved in an ad hoc investigation of seemingly above board process, the mission and its ennablers were clear to see. The laziness with which the chain of incompetence and criminality was covered up was breathtaking.

In aviation, the burden is borne by the common man, through taxes, and the product is consistent with most ventures assigned to the public 'servant'.

Government work.... "You want me to go the Moon aboard a device built by the lowest bidder?"

I have great respect for the FAA, EASA, and BEA, though that may raise an eyebrow or two. By and large, these are competent, and professional organizations. Asx they are public, Politics rears its drooling jaws, and leadership is awarded to whomever purchased more lunches or green fees for the Appointing wonk....

By and large, most of the sheer stupidity and underhandedness is found out, but generally because someone left the lights on....

The larger the consolidated process, the more power, and the more chance for hiding the truth.

Converesely, the smallest organizations tend to be the more corrupt, the consenting few make up the majority of the workforce, and so are well disposed to self protection.

Fukushima is a beacon and clarion. I see ample room for this accident (447) to accomplish some dark corner illumination, you?

Thanks for the action,

A33Zab: Yes, the Stick was fine, I personally am broaching the topic of feel, and PJ2 says Neutral is easy to suss.... So.. He establishes a climb as neutral, and builds and builds....Que paso?

PJ2... "Neutral". Someone needs to at least offer a possibility why PF chose to climb, and appeared not once to be satisfied.....With ADI, and a nosy PNF?

Duff ADI? not the first time, if at all.....What was PNF using then ISIS? Why was PF unaware, demonstrably, of his PITCH, or altitude? And since the climb was NEVER (assimilated) here is the cause, the precise cause. Now we hone in on the possibilities...... If someone, a neutral, is allowed to hear the CVR from 20 seconds either side of 2:10:05, I'll say fine. Complete, tested, and authenticated.

Come on Lyman, BEA playing games?

[PJ2]

Lyman;
PJ2... "Neutral". Someone needs to at least offer a possibility why PF chose to climb, and appeared not once to be satisfied.....With ADI, and a nosy PNF?
I am counting on the BEA Human Factors Group for this. Many here have posited serious and plausible theories to account for the sustained NU input. Early on, the Airborne Express DC8 accident was introduced as a possible explanation - the natural tendency to pull back if going down; - the DC8's control column was held in the full-NU position all the way to impact, as was the case with the Northwest Airlines B727 accident. The memorized UAS drill has been discussed, with sub-theories attending to a general inexperience in high-altitude manual handling of transport aircraft throughout the industry possibly pointing to a correct but over-controlled input by the PF and tolerance by the PNF while the PF settled the response down. Inadvertent, unintended NU input while responding to the right roll has been discussed.
The laziness with which the chain of incompetence and criminality was covered up was breathtaking.

In aviation, the burden is borne by the common man, through taxes, and the product is consistent with most ventures assigned to the public 'servant'.
In examining the U.S. political economy and events which led to October 2008 and the numerous boom-bust cycles from the Nineteenth Century on, yes, I agree with all your views. Dekker and others have written about "what's common" between aviation, medical and economic "accidents" and I think there is fertile ground for decades of research from which ad-hoc societal change will emerge. The masses will eat cake for only so long, so to speak, but, except for very specific areas of concurrence when it comes to why organizational accidents occur, we are way off topic. I re-emphasize that I think Vaughn's book is the reference work for highlighting the shift from assessements of amoral calculation to the normalization of deviance, which, I believe, is far more prevalent as an operative factor in organizational behaviours, at least in high-risk enterprises, than the former.

[A33Zab]

A33Zab: Yes, the Stick was fine, I personally am broaching the topic of feel, and PJ2 says Neutral is easy to suss.... So.. He establishes a climb as neutral, and builds and builds....Que paso?

Ok, and that's exactly reason to investigate the seat/armrest position:


"We are continuing to examine the pilots' seats to try to understand if the adjustment could have influenced their inputs on the sidesticks."

[Mr Optimistic]

Has there been further consideration of the ACARS messages and are they now fully understood. Will the final report deal with this?

[grity]

A33Zab implausible with dual cartridges:for the caracteristic of the SS the stronger spring must have space for the first 6.5 mm, (your nice picture is not exact in this detail) if the weaker spring was broken then the neutral aerea is between +/- 6 deg of handle deflektion.....

there are two dual cartridges so the risk will be seldom x seldom...... what is very seldom....

[Machinbird]

grity, For springs not operating in the yield range, the lifetime is very long, in the millions of operations. For a dual failure under this condition, the probabilities suggest that the first failure must not be observed, and the system continues to be operated with a single cartridge providing feel. If this case is valid, then the probabilities of two broken springs on the same flight move into the possible range.

We have to ask the 'Bus maintainers and pilots, the likelihood of a single failure not being written up within a reasonable period of time ~ 6 months max.

Pilots might like a softer feel to the spring cartridge and might not write it up.

Maintainers have periodic checks that they do on everything. The question is not how often this is checked, but how often is it checked using a method capable of reliably detecting a partial spring failure.

[TTex600]

We have to ask the 'Bus maintainers and pilots, the likelihood of a single failure not being written up within a reasonable period of time ~ 6 months max.

Pilots might like a softer feel to the spring cartridge and might not write it up.


I know of no Airbus pilot that would take any chance at all when considering aircraft control. Unless an Airbus pilot is totally inept, he/she is acutely aware of the tenuous link we have to life and won't take any chances. I would put the chances of a pilot ignoring a soft stick at exactly zero.

[OK465]

I would put the chances of a pilot ignoring a soft stick at exactly zero.

:eek:

You got that right. There's medication available now. :}

[CONF iture]

Yes, he did pull back, intentionally or not, we don't know:
2 h 10 min 07: The copilot sidestick is positioned: - nose-up between neutral and ¾ of the stop position; VS and VSsel are both zero.
2 h 10 min 08: The FD 1 and 2 become unavailable.
2 h 10 min 17:The FD 1 and 2 become available again; the active modes are HDG/ALT CRZ*. VS is then 4000 fpm.
Time 2 10 07

VS is not zero but minus 500 fpm
The altitude shows 200 feet below the assigned flight level
The attitude is below the horizon
Every reason for the PF to initially pull.

Time 2 10 08
Bizarely AP has already disconnected but FD are still displaying, probably for a nose up command.

Time 2 10 17
After dissapearing, they are back, but for a few seconds only, in ALT CRZ*
The altitude is very close to 35000 feet so the FD must indicate a sharp nose down command if the VS is still at a positive 4000 fpm.

Time 2 10 26
Again FD are back, is it for a 10 seconds period, but it must be in VS mode this time.

Alain Bouillard – .......
To try to understand the pilots' actions I have decided to set up a human factors group that will study the behaviour and the actions of the pilot, containing specialists in ergonomics, cognitive sciences -- psychologists, and doctors specialised in aviation.
We are continuing to examine the pilots' seats to try to understand if the adjustment could have influenced their inputs on the sidesticks........
Before studying anything in that direction, we need to see the Vertical mode trace and analyze how and if the FD may have influenced the PF inputs.

[Old Carthusian]

CONF iture
An altitude 200 feet below the assigned level is not in itself major reason for concern and it doesn't look like the PF's reaction to this situation was appropriate. I am also interested as to where you derive your nose down attitude from. There is no evidence that the FD was feeding the pilot false information and you are just introducing another red herring.

[RetiredF4]

OC
I am also interested as to where you derive your nose down attitude from. There is no evidence that the FD was feeding the pilot false information and you are just introducing another red herring.
OC

BEA IR3 page 88
02:10:00 Pitch attitude decreases from 1.8° to 0° in 3 seconds.
Also visible in the FDR readout on BEA IR3 page 111

You shouldn´t be that fast with red herring.


In FL350 a 0° pitch can be considered a nose down attitude, as the aircraft won´t maintain level flight anymore. The crew had to react, that it ended in an unexplainable overrreaction is another thing.

[HazelNuts39]

Also visible in the FDR readout on BEA IR3 page 111Even better on page 42.

[roulishollandais]

HN39,

You said C * :
This means that the feedback of the control law changes at a speed close to 200 KT (not mentioned by AIRBUS in our reports, to my knowledge).
To lower speeds the pitch rate is used in the feedback; at high speeds feedback is using G. :p
When the speed is correct, with 3 correct ADR, the smoothing of the two feedback goes well.

But in the AF447, speed selected for that smoothing is either false, or switching from one value to the average of two dissimilar, then the feedback leaps and bounds in the loop! :E
Therefore we must expect APC / PIO (aircraft pilot coupling / pilot induced oscillation) !
1. The initial PIO pointed to by Machinbird may be born of such a discontinuity. :}
2. Other APC have been born then at the option of pitot failures (curve of the three speeds is very discontinuous) creating "non-surmountable" (CVR) instabilities in pitch and loss of control. :E
3. The very rapid oscillations of the parameters from 02:11:40 may perhaps be explained as well. We never got to overcome the possible output of the stall and we never discussed these oscillations that trouble me since I've seen these oscillations.:{

[PJ2]

A slight loss in indicated altitude seems to accompany a UAS event.

From the Air Caraïbe A330 UAS Report (http://www.slideshare.net/Unusualattitude/air-caraibes-airbus-a330-memo) written by Hugh Houang, January 12, 2008
Phase 3
A 22H22 et 59S, on enregistre une diminution très rapide de la « CAS », du mach et de l'altitude (correction de mach). Ces paramètres passent respectivement de 273KT à 85KT, M0.80 à M0.26 et de 35000FT à 34700FT. Au même instant, les « FD1&2 » et « l'AP2 » à se deconnectent.
. . . .

A 22H24 et 25S, la « CAS » augmente de 111KT à 275KT, le mach retrouve sa valeur initiale M0.80 et l'altitude augmente brutalement passant de 34200FT à 34500FT.

Translation:
At 22:22:59, a very rapid decrease of CAS, Mach and altitude (Mach correction) is recorded. These parameters respectively decrease to 85kts from 273kts, M.26 from M.80 and 34.700ft from 35.000ft.
. . . .

At 22:24:25, the CAS raises from 111kts to 275kts, Mach returns to M.80 and altitude abruptly raises from 34.200ft to 34.500ft.

[HazelNuts39]

To lower speeds the pitch rate is used in the feedback; at high speeds feedback is using G.My knowledge of these things is limited to the bits I picked off this thread. My understanding is that throughout the speed range the feedback is the response of the airplane in terms of pitch rate and Nz. At low speed the pitch rate is dominant, and at high speeds the Nz is dominant, but both components are present all the time. The response of the airplane in terms of q and Nz is not affected by errors in the measured airspeed.

[Lyman]

It was established some time back that the 367 foot difference in recorded altitude was an anomaly. I buy that, but remember the crew had no knowledge of that.

I'll leave it to others to review the data. For the record, the PITCH was accurate, at '0', the altitude was displayed as 200 feet low, and the speed? The Roll correction was met with 'twitchy' response, the airmass was turbulent, the cockpit noise was unknown (sic), etc. Weather, Dark, Surprise, mind how you go.

I'll simply remind everyone that you were not there, and I venture to say that the upset found its beginning in the initial handoff. Look at some of the actual (inertial) vertical data points, remember the conditions, and try to avoid judgment of the outcome based on the initial record......


re: IA What he said, V V V V V V

[HazelNuts39]

PJ2;

The 300 ft drop in indicated altitude is explained in IR#2, para. 1.6.11.6 Consequences of a drop in the measured total pressure (p.49). At cruise AoA the pressure at the static port is slightly higher than the true ambient pressure. The measured static pressure is therefore corrected by a term that is proportional to airspeed-squared (or Mach^2). That correction is essentially lost when the pitot pressure drops to a low value.

[mm43]

The TAT/SAT/Mach anomaly is demonstrated very clearly in this ATSB FDR traces graphic of an UAS event to VH-EBA on 29 October 2009.

http://oi48.tinypic.com/2urtro8.jpg (http://oi55.tinypic.com/23lfk8k.jpg)

Click on the image to see full size graphic.

[grity]

I would put the chances of a pilot ignoring a soft stick at exactly zero.
please do not set the possibility of any mechanical mistake to exactly zero, as long as no one know "why he had pulled in this way"

mayby it is 1/100000 but truly not zero

[Lyman]

grity, Tex was not addressing the likelihood of actual failure, merely in his opinion, he thought an Airbus pilot, if he knew, would write it up, immediately, every time.....

[PJ2]

HN39;

Thanks very much for the information - much appreciated.

CONF iture,

From a pilot's p.o.v I think the theory that the reduction in indicated altitude as an initiating source for the immediate pull on the stick by the PF is reasonable in and of itself, however it does not account for the destabilization of the flight path and rapid loss of control that follows. As for the theory of two pilots slavishly following their flight directors to the exclusion of all the raw data being presented, we may posit what we wish but it is not possible to draw any conclusions either way.

[CONF iture]

From a pilot's p.o.v I think the theory that the reduction in indicated altitude as an initiating source for the immediate pull on the stick by the PF is reasonable in and of itself, however it does not account for the destabilization of the flight path and rapid loss of control that follows. As for the theory of two pilots slavishly following their flight directors to the exclusion of all the raw data being presented, we may posit what we wish but it is not possible to draw any conclusions either way.
No conclusion at this time, but considering both AD + one OEB + the data, one must consider in priority what were indicating the FD when displayed. At this time I see far too little in the 3 IR on that subject … Also, I am still very much concerned we still have to be presented the vertical mode trace ?

Regarding the initial maneuver, it is not only the reduction in indicated altitude, but also a negative VS + an unusual low pitch for a cruising FL.

Blindly following the FD is not a thing to do, but I am afraid signs here could let us think that’s possibly what happened.

[Lyman]

@PJ2

however it does not account for the destabilization of the flight path and rapid loss of control that follows.

No. I have virtually always used it is a beginning, however. To connect the initial manual responses to what happened, may not be so inexplicable, with patience, and an objective and sincere attempt to put one's self in the cockpit.

I have. I am not ATPL, but a pilot, and what I feel when I get to Bonin's seat scares the **** out of me... I can make it real. I have sat mesmerized while some one on the right tells me something I need to do, and I nodded, and did not do it.... I have gotten behind, in turbulence and inadvertent IMC in a VFR ship, and nearly crapped my pants. I praise God for the quality of the aircraft I have flown, and the forgiving nature built into most a/c.

[OK465]

I would add 2 things to the FD discussion...

1. They had most probably never seen a situation where the FD bars disappeared and then returned

2. As A33Zab says, the bars flash for a short period and then go steady (like the flashing lights on an ambulance can draw your attention before you hear the siren)

Most of the returns weren't long enough for the bars to go steady, but the return when pitch had finally been reduced to 5.6 degrees would have flashed AND then gone steady, possibly a falsely reassuring appearance of overall system validity...

Three more things...

1. At the apex, it would only take a couple of seconds of ill-advised following of what could have been a fairly subtle initial FD command to stall the aircraft, the subsequent initial aircraft reaction and physical flight indications not necessarily being a 'hit you over the head' indication of a valid accompanying SW audio.

2. The FD's should not have remained selected

3. We'll probably never know

[Old Carthusian]

Franzl
The evidence there is that the PF induced that particular nose down attitude 'There, I've taken it down a bit' to quote. The human element is still the major issue here. Bringing in the FD obfuscates the circumstances and qualifies as a red herring in my book. There is no getting away from the impression that this particular flight crew was thoroughly incompetent.

[jcjeant]

Hi,

Old Carthusian
There is no getting away from the impression that this particular flight crew was thoroughly incompetent. This impression (if it is every bit true) leads to several questions:
Is that the system of training and selection of Air France and the french civil aviation formation should be questioned?
Is what the instructor pilots of Air France are qualified ?
Is the management of Air France has sufficient attention to these formations and selections ?
Are the aircraft manufacturer informations out dated for the conduct of flight ?
Is that the training and selection criteria are out of date and have not be adapted to contemporary needs by regulators ?
Will the BEA put in light those questions in his final report ?

[CONF iture]

The evidence there is that the PF induced that particular nose down attitude 'There, I've taken it down a bit' to quote.
Do not see evidence where there is none : The PNF is talking about the mach reduction in order to conform to the speed for turbulence, not the attitude.
A speed reduction induces a higher pitch, not lower.

[Old Carthusian]

CONF iture
It can be read both ways and this is what I wanted to bring out. Selective reading of the evidence is never a wise thing and the truth no matter how painful it is needs to be faced. We will not know exactly what happened but the information we have points to human elements and has done ever since the CVR was decoded. Everything else is just fluff
jcjeant
Those are very pertinent questions and I think they do hit at the core of this accident. I have always thought that the Air France culture was part of the issue and the background.

[Lyman]

OLD CARTHUSIAN:

No. And No. Retired F4 refers to the Nose Down at 2:10:00, when the aircraft was on autopilot. Hence the pilots had nothing to do with the Nose Down Pitch.

Are you now claiming the autopilot was incompetent??

If so, let's begin...

Quote (from BEA pp 88):

"...02:10:00 Pitch attitude decreases from 1.8° to 0° in 3 seconds.
Also visible in the FDR readout on BEA IR3 page 111..."


Response?

[bubbers44]

We always should consider the autopilot incompetent. Never trust it, just use it to reduce workload but never trust it. You, the pilot,are the only thing to trust presuming you can hand fly an aircraft when automation fails.

The old guys know this.

[HazelNuts39]

The AP just did the job assigned to it: maintain altitude while traversing an upward gust.
Image posted earlier:
http://i.imgur.com/igxsK.gif?1

[Lyman]

HN39

For refernce only, what headwind would have been necessary to trigger Overspeed, at the 2:10:02?

[HazelNuts39]

Lyman,

The steady headwind doesn't matter. At ISA+15.6°C a sudden head-on gust of 30 kt would have increased Mach from 0.815 at 02:10:02 to 0.866 (Overspeed warning threshold Mmo+0.006).

Please note that in two zoom-climb incidents overspeed warning was triggered without triggering the overspeed protection.

[RetiredF4]

OC
Franzl
The evidence there is that the PF induced that particular nose down attitude 'There, I've taken it down a bit' to quote. The human element is still the major issue here. Bringing in the FD obfuscates the circumstances and qualifies as a red herring in my book. There is no getting away from the impression that this particular flight crew was thoroughly incompetent.

OC, there is no evidence at all that this phrase at 02:09:54 is related to giving up height. It could be related to the change of radar scale or the reduction of speed (most probable) but not to the altitude.

You are entiteled to make the assumption concerning FD display being a fact or a nonevent, but it´s not correct to use incorrect statements with it and disqualify stated facts of other posters (in this case the attitude of the aircraft) as being a red herring.


There is no getting away from the impression that this particular flight crew was thoroughly incompetent.

Unfortunately most of us have to agree on that statement.

[AlphaZuluRomeo]

Regarding the initial maneuver, it is not only the reduction in indicated altitude, but also a negative VS + an unusual low pitch for a cruising FL.
This seems to be a very reasonnable explanation indeed.

But, given the situation:
360ft too low
pitch 0° when it should be ~2.5°
V/S negative when it should be 0.
How is it logical/reasonnable to engage such a climb that you get:
3000ft+ too high ultimately
pitch more than 10°
V/S far too much positive

:confused:

[CONF iture]

How is it logical/reasonnable to engage such a climb that you get:
•3000ft+ too high ultimately
•pitch more than 10°
•V/S far too much positive
Sure, none is reasonnable.

In the meantime, it has to be mentioned that the initial action is suggested by the horizontal bar for vertical navigation. At this time the AP/FD vertical mode is still most probably in ALT CRZ. The negative values must have sent the horizontal bar pretty high on the PFD. What I don't get is why the system decides to dump the AP but thinks it smart to still display the FD for 3 more seconds.

In this short period, with warnings and turbulence, there is absolutely no chance for the crew to identify a case of UAS and apply its memory items.

[Machinbird]

I am not ready to declare the AF447 crew to be incompetent, only their performance as incompetent. I can understand being a bit brain dead at 2AM.
(Seems to happens to me at work at 2AM routinely nowadays:})

A paragraph taken from the NTSB report on the AA landing incident in Jackson Hole seems to fit AF447 pretty well:
The incident highlights an issue that has arisen in recent accidents around the world: today's automated, reliable aircraft can breed complacency in pilots, the **** concluded.

A simultaneous series of events aboard the jetliner prevented its****** systems from functioning, the investigation found. The pilots, distracted by the initial failures, could have ********* had they manually ******* some of those systems, the agency concluded.

"This incident demonstrates that experienced pilots can become distracted during unusual events," .........and lose track of what is happening with the aircraft.

[Clandestino]

Forgive me my ignorance, it was yourself, who put the discussion back to this simple term.Because it is simple: CM2 pulled the aeroplane into stall and kept her there. That's why it fell.

alternate Law? for UAS? Why? Because alternate laws are must-have fail-safe, mitigating the risk of untimely activation of overspeed and alpha protections! Computers are unintelligent and get more easily confused than humans, that's why they refrained from intervention when the aeroplane was stalled. Wet dream of many a PPRuNer asking for more direct control in Airbus turned out to be a hellish nightmare.

Scan and knowing what procedures to apply are better improved by repetition, eh? Yes, but instrument scan, understanding the aeroplane's position & behaviour and manual dexterity in manipulating the controls are not inseparably connected. True, you have to be very good to in all of them, all of the time to be a good enough instrument pilot but there's no difference between instrument scan when flying manually or when AP is on (except you can get away with more easily with lazy or inexistent scan when George is in charge) and procedures can be reviewed in one's head while serenely cruising, or standbying at home or whatever. As any technical discipline, flying can only be mastered in crawl-walk-run sequence. People struggling with basic aerodynamics will have no idea what is behind the memory items, will learn them by rote just to pass the checkride and stand good chance of misremembering or misapplying them at 4:00 AM, no matter how many time they repeat the mantra.

Clandestino and Dozy are banking heavily on two pilots completely losing the ship to Stall, with nary a whimper. I don't believe it. Being realist, I believe whether you, I, anyone else and his dog believe or not, it will not have a slightest effect on what has already happened. If anyone in cockpit recognized a stall warning for what it was and acted accordingly, we wouldn't be having this thread. Eighth.

He hadn't heard the Stall warn yet, so we can eliminate a rote response to approach to Stall, etc.....etc....Rote response to stall warning would have saved him and everyone on board.

Meanwhile, the aircraft has been in a stable cruise without any obstacle clearance problems and has the potential to keep doing so, so why would any sane pilot want to disrupt that process just because some of the instruments are confused? Shock, horror, surprise, followed by panic and disorientation.

Rote application of an emergency procedure without understanding the appropriate circumstances has downed more than one aircraft. Yes. Rote application of wrong procedure did. Rote application of right procedure didn't, even if its application was by sheer chance.

It remains to be seen whether AF447 is indeed the canary in the coal mine for more LOC accidents of this type.No. Few examples of canary in coal mine were Pinnacle, Armavia, Gulf Air, Colgan, Birgenair, Aeroflot Nord, Alitalia 46 at mt Crezzo... it's just we disregarded them with a bit of applied jingoism: those killed were Russian/drunk/Arab/regional jet jockeys/Italian/turboprop drivers/ex-military/etc. Now when it happened to western built and operated widebody, amount of irrelevant and plain wrong theories put forward on PPRuNE to compensate for our inability to face the facts is amazing thing to behold.

The primary decision-point is based upon whether the safety of the flight was impacted. That is an entirely subjective matter, as is evidenced by the differences in opinions offered on the matter by those who do this work. It's a joke, right? Some slight subjectiveness can never be totally eliminated but pilots whose estimations stray too far from objective are bound to get hurt.

The "5deg pitch above FL100" is misleading and wrong
It is not wrong and it is not obligatory.

A 5° pitch attitude isn't going to stall the airplane any time soon.It will never stall an aeroplane as long as there is sufficient power available. With 5° pitch maintained, aeroplane climbs, power drops, AoA goes up until level-off at 5° alpha is achieved. Any aeroplane.

Is that intended as a 'slap on the wrist' or do they mean 'well done'? Accident reports indulge in neither. It is a statement claiming following the memory items is definitively not necessary for successfully dealing with UAS.

No other tool that fully visible control columns can better enhance crew coordination - It is all about naturally sharing first hand information - A crew needs sharing, not hiding. >sigh< Let me try it this way: was AF447 really the only case of UAS in cruise on A330/340 fleet so we should base all our judgments about Airbus FBW cockpit design solely on it or do we perchance have some other incidents to check how other crews behaved and see whether the UAS on the Bus is really bound to be lethal by virtue of sidestick design?

The PF does not know where neutral isTo find where the neutral is, let go of stick. Were springs broken? Extremely probably not; no mention of it on CVR and CM2 successfully reduced pitch from 12° nose up to 6° before stall warning went off second time and inane pull was repeated. So no traces loss of control in pitch. Aeroplane did as commanded.

Every reason for the PF to initially pull.That's very selective reasoning. Once aeroplane was back at FL350 indicated, there was no reason to pull anymore, yet he pulled and pulled and pulled, reaching an apogee of FL379, 2900 ft above cleared level. If there was a reason to keep pulling, it was not on altimeter anymore.

In FL350 a 0° pitch can be considered a nose down attitude, as the aircraft won´t maintain level flight anymore.In real life there are: turbulence, updrafts and downdrafts. 0° pitch can be perfectly acceptable transient cruise pitch.

[A33Zab]

What I don't get is why the system decides to dump the AP but thinks it smart to still display the FD for 3 more seconds.

between 02:10:05 and 02:10:07 FD2! (RH PFD) was not engaged.

one second remain, before both FDs were not displayed @02:10:08.
for that second the Nz delta was ~ -.15g....(Nzdemand 1g - Nzactual 1.15g).
IMO FD bar position would have been ND and minor.



AMM: 22-11-00

(1) Generation of FD bar commands

(a) Pitch FD bar command

The pitch FD bar command is computed by using the measured vertical acceleration (NZ) and the NZFD command (pitch outer loop).

[OK465]

It will never stall an aeroplane as long as there is sufficient power available. With 5° pitch maintained, aeroplane climbs, power drops, AoA goes up until level-off at 5° alpha is achieved. Any aeroplane.....


.....except an aeroplane with a stall 'angle of attack' of less than 5 degrees. :)

[PJ2]

Clandestino;

Thank you for your responses to my comments.
Quote:
Originally Posted by PJ2
The "5deg pitch above FL100" is misleading and wrong

It is not wrong and it is not obligatory.In reverse order... First, we're arguing the same point but for different reasons. I have always argued that the initial memory items (regarding the 5deg pitch attitude above FL100) were not obligatory but you continue to misunderstand the point of all my posts on the topic. The drill was indeed viewed as obligatory as far as the BEA was concerned (in their press conference) and as far as many on this board were/are concerned.

Note - edited to clarify the notion of "obligatory" and the execution of this drill:
The drill is obligatory in the sense that there is an abnormality and there are memory items associated with the abnormality. In this case, the first memory items are bypassed because they don't apply, because the airplane is above circuit altitude and above MSA. The memory item is, "level off and troubleshoot". It is not obligatory to pitch up to 5deg. That has always been my argument.

The point of my early and ongoing interventions was to provide reason to re-consider the assumed-obligatory nature of the drill and (see above) to question or at least think about why anyone would pitch a transport up while in stable cruise. The FCTM and various Airbus documents, some of which I have posted links to, indicate that automatically pitching up is not the correct response.

For the longest time, no one here agreed with that view and kept reaffirming that the correct response in all circumstances was first, pitch up, then re-stabilize the airplane.

The fact that a 5deg pitch isn't as harmful as a 15deg pitch-up is beside the point: Why pitch-up at all when in cruise flight just because the pilot considers that there is "immediate risk to the safety of the flight"? Where is the "immediate risk"? In my view, there is apparently far greater risk in destabilizing the airplane in cruise flight than in keeping it level, for troubleshooting. Thirty-odd other crews seem to have agreed with this view.

It is in this manner that I consider the UAS drill "wrong"...perhaps too strong a word, but the drill is, clearly, poorly-written. While others may not think so, I think that that requires an examination.

The memory drill's first question is, "is the safety of the flight at risk?" That is a crew decision which directs their response one way or another.

That is an important decision and I submit that the question, "is the flight at immediate risk" is more subjective than a decision based upon, say, flight phase. I'm trying to consider a way of making the response more clear. I considered flight phase to be a natural way to do this and gave some thought to a re-designed drill as per a recent post.

You will agree will you not, that loss of airspeed indications during the flight phase AF447 was in, is not nearly as serious as losing airspeed information during the low-altitude takeoff-initial climb phase? The intent of the pitch attitudes stated in the memorized portion of the drill was to provide immediate, safe numbers for such failure in a flight phase where looking up the numbers isn't possible. In cruise, the airplane is already established and in a stable flight phase and the crew has time to respond differently, as per the last memorized item, "when above circuit altitude or MSA, level off and troubleshoot".

Regardless, the main point I have always made and which you continue to miss is, Why destabilize a transport aircraft in cruise flight when a better course of action is to keep the pitch and power settings which existed prior to the failure? I made the mistake of stating that a pitch up to 5deg would lead to essentially the same result as AF447 and I was wrong and have corrected and stated that view a number of times. Please, move beyond my original mistake and argue if you will, from the present point being made.

[Lyman]

In layman's terms, but no less accurate:

A decision to do nothing... is still a decision. That is the point being missed, imho.

Perhaps a bit existential, but... The stage is set for doing the wrong thing when after a career of doing nothing, it feels as though, "something must be done..."

Lack of familiarity through "hands off" can lead to danger when necessary to "hands on"....rote, memory, feel, all are crusty from disuse, and not readily available in an emergent situation..

Machinbird, step in anytime....

[Flyinheavy]

@PJ2

[QUOTE]The memory drill's first question is, "is the safety of the flight at risk?"
That is a crew decision which directs their response one way or another.[QUOTE]

I think, they never applied this procedure anyway. They lost A/P at 2:10:05 and PF says at 2:10:14 "we haven't got a good display" to complete the phrase at 2:10:18 "of speed", while PM says at 2:10:17 "We've lost the speed etc.."
without any mentioning of UAS procedure.
If the transcript is real it shows that there was a lot of confusion and in fact no action only reaction of the PF to whatever situation he thought they were in.

As to the "There I've taken it down a bit" comment of PM at 2:09:54 it obviously refers to >Copilot's ND scale changes from 80NM to 40NM< at 2:09:53, so clearly no reference to pitch or speed as some were posting here.

[PJ2]

Flyinheavy;
The memory drill's first question is, "is the safety of the flight at risk?"
That is a crew decision which directs their response one way or another.[QUOTE]

I think, they never applied this procedure anyway.We actually don't know if the PF was applying this procedure or not as his actions were never announced nor was the PNF included in what was happening as the PFs actions took place. What we do know from the CVR is that no normal/abnormal ops SOPs and no CRM procedures took place. We cannot attribute the pitch-up to anything, with any certainty, we can only consider what may be plausible or not and look for minute clues which are always interpreted. If we are not mindful in this process of attributing cause, the risk is that we get into the problems that alf5071h has made contributions on, hindsight bias, or that willingness to substitute or at least think about what we think should have happened for what we can only, actually hear and see in the recordings.

I have long posited the notion that perhaps the pitch-up was due to a remembered response in training, right after takeoff, of the UAS memory items, but there are equally interesting notions that explain the pitch-up in quite different ways.

And even after the pitch-up and before the stall the airplane was controllable using normal control inputs, (getting the nose down), but in absolute terms, the stick was in the NU position more often than it was not, prior to the stall. The potential for a complete and rapid loss of situational awareness is high in these circumstances.

To be sure, there is much more behind this than a mere pitching-up of the airplane for which we do not know the reasons. In terms of manual flight the airplane is very easy to handle at cruise altitudes and it would have been straightforward to return the airplane to cruise flight. The task is to understand why it went the other way.

[gwillie]

Watch "Vanished: the Mystery of Flight 447," on a special edition of "Nightline" TONIGHT at 11:35 p.m. ET/PTAir France Flight 447 Investigation: Pilots Not Properly Trained to Fly the Airbus A330? - ABC News (http://abcnews.go.com/International/air-france-flight-447-investigation-pilots-properly-trained/story?id=16503005)

[Machinbird]

Quote:
Originally Posted by Machinbird
Meanwhile, the aircraft has been in a stable cruise without any obstacle clearance problems and has the potential to keep doing so, so why would any sane pilot want to disrupt that process just because some of the instruments are confused?

Shock, horror, surprise, followed by panic and disorientation.
Hey Clandestino, we are talking about trained pilots, not random guys you pick up on the street. The only emotion an actual pilot might experience should be surprise. If any of the other emotions are being experienced, then that person doesn't belong in a cockpit without further training to convert those negative emotions into positive and considered action. Flying is not supposed to have a lot of emotion attached to it other than appreciation for the beauties of the sky and the earth.:cool:

[alf5071h]

“… is hindsight bias a conclusion in itself…´Lyman #1084:
Bias is a tendency to hold a view which may affect our thinking; thus hindsight bias is not a conclusion unless we consciously choose to hold that view.

If we consider foresight as a process of judgement acting on information, then we have to establish if the information necessary for the judgement was available and known by the judge. Only then can the quality of the judgement be debated. Such judgement involves risk assessment and the determination of an acceptable level of risk – as low as reasonably practical (ALARP); but then who sets the standard.

In many ways this process is similar to that in determining the level of acceptable behaviour in a ‘Just Culture’, and using Dekker’s view – “it’s not the value the line which is important, but who sets it".

Previous A330 ice crystal / ADC / ASI events may have concluded that flight into such conditions was an acceptable risk because of the non-fatal outcomes (with hindsight).
AF447 was an unacceptable outcome which suggests that foresight failed; but the process of foresight was identical with previous events, thus if this is unacceptable, what risk (information) should have been judged.
Differences between previous events and AF447 might indicate a reason for the severe outcome (what), but this only represents the additional risk in that one event. It’s the difference amongst the events before AF447 which might identify the relevant contributor to the risk (why).

One difficulty with this line of thought is that irrespective of what factors are identified and mitigated, there is still some residual risk; it is probable that AF447 fell into this category.
To progress safety the industry requires to take a more abstract view for continued airworthiness (systems thinking), vice the probabilistic based certification view; and will need to apply generic safety nets to catch residual events. Aspects of these were covered by PJ2 @ #1037.

[Lyman]

alf5071h

Differences between previous events and AF447 might indicate a reason for the severe outcome (what), but this only represents the additional risk in that one event. It’s the difference amongst the events before AF447 which might identify the relevant contributor to the risk (why).

Are you certain you are not Santa Claus in test pilot rig? Assigning 447 an equitable position on the evidence table is kind, to be......kind.

There not only existed no foresight, there was foreblind.... Actively avoiding a field of 'best practice', the players and the odds were not in the group usually assessed as a standard statistical population.

Hindsight bias is merely a point of view, as you say, one may choose it. It has no place in a strict investigatorial venture, but this ain't that.

It is, or should be, obvious, that foresight is not quantifiable, hence subject to human failings in its application. Interdisciplinary overlay is no excuse to reduce the rigor of a culture of impeccable safety. And it is not expensive... That is the annoying irony. Most of what is lacking is merely what needs be done as part of the job description, hence, it is prepaid....

There is criminal negligence here, in spades, IMHO. Bets are off; risk management, as odious a term as it is, was nonexistent, though it was no obstacle to the mission!

I can appreciate your point of view, but analyzing 447 as a 'case study' is wildly impractical, there was no structure on which to hang the minimum.

[Machinbird]

Lyman, if you were in charge of the AF safety program, and AF447 had not yet happened, what would your basis be for grounding the entire fleet of A330 aircraft until the pitot probes were changed out? You have perhaps 30 examples of pilots coping successfully with frozen pitots. How do you justify your position to management? How do you justify an expansion of the pilot training program to include relatively rare failures at altitude (where there should be plenty of time for corrective action by the crew.)

As I implied earlier, the legal profession tort process makes its living from peoples' inability to exercise perfect foresight.

It is relatively trivial to exercise perfect hindsight.:rolleyes:

[john_tullamarine]

It is relatively trivial to exercise perfect hindsight

True .. which is why most of us don't get too entrenched in Monday morning quarterbacking.

How do you justify an expansion of the pilot training program to include relatively rare failures at altitude

Certainly, one wouldn't head off down a path of kneejerk training reaction.

However, one MIGHT, as part of normal, prudent risk management processes, consider whether there could be a problem ?

I would have expected Flight Standards Management (not just AF, but any operator of the Type) to have put a small sample of line pilots into the simulator to observe what their responses might have been to such events ? The outcome of such an experiment might then have suggested whatever when it comes to training program variations.

[Machinbird]

I would have expected Flight Standards Management (not just AF, but any operator of the Type) to have put a small sample of line pilots into the simulator to observed what their responses might have been to such events ?
John, that seems eminently prudent.

As a former military aviator, there are large holes in my understanding of how the airline side of the world goes about its business.:O I try to constrain myself to stick and throttle matters.

[Lyman]

First identify there is a problem... Wait and see seems to have been the drill. AF had (has) a leadership problem, it shows from all the ridiculous commentary post crash. Only Public Relations? No. Indicative of no one in charge.

There was a cluster of nine UAS events at AF in the year around 447. I think I'd have been tempted to organize a special program to isolate that data and use it to saturate an intensive focus by several check pilots, in parallel with Airbus pilots, and narrow the scope to creating a very strict profile of who flies where, and when, tighten up the roster on an emergency basis, and perhaps assign a safety pilot on a temporary basis to fill out the cockpit. Engage the crews who had experienced the events, put together an interim, "here's how", "do's and don'ts", etc.

No grounding necessary, though I would seriously consider a dead head home event for each a/c, similar to what UAL did when, after BA038, United's eighty eight T7s were ordered immediately stateside to undergo immediate inspection of fire bottles. The inspection was deferrable, but they hobbled their operation to do a gd line check.

I could be wrong, but the nonchalance apparent at AF was breathtaking. The crew of 447 was a wild card, that is not a difficult call to make, and issues of rest and command, experience, etc. should have been on alert until the challenge was completely quenched. Dubois had failed a check ride, ordinarily not a huge deal, but it would have flagged him (possibly) for a vacation from ITCZ flights until these events were better understood.

You could easily say this is all hindsight. I like to think that from what has fallen out, it may be ascertained that much more should have been done. Look at the flight path of each incident a/c. You fly small and fast, in the airline business, wandering around the sky is a no no. Flight Path loss is serious. No, Critical, perhaps not in and of each event, but for what it suggests, could go wrong as follow on to unidentifeied behaviour.

[Old Carthusian]

Lyman
You're right - this is not hindsight but something which can be spotted in a professional and efficient organisation. Air France's own audit highlighted issues with flight crew but these weren't addressed. It is thus the case in all the airlines which develop corrupted cultures.

[Lyman]

OC.

As I see it, there are no facts that haven't happened; everything we write is based (or suggested by) facts. Looking back is looking back, forensics. BEA may have some suggestions, but with management/leadership issues, it's more difficult. Culture is squishy, v/v regulation.

[PJ2]

Looking back is looking back, forensics.
I think so.

What about this as one working understanding:

There is no "hindsight bias" in examinations of the recorders or other factual records. It is only "bias" when we substitute or subtlely (or not) dress the facts with what we think should have been done "but wasn't".

Theories about what happened and why are not hindsight bias because they are just that: theory. Theory describing possible/plausible cause(s) is not fact until established by what is known from the record.

Bias is revealed by statements like, "I can't believe that a crew could...", or, "Why didn't they...", or "Well, obviously...", and promotes what we think, perhaps even logically so and from our experience, should have happened, and proceeds from that point towards discussions of cause(s), under the assumption that it is still proper investigative technique.

Clearly it is more complicated than this and there are areas of cross-pollination which are difficult to steer clear of or engage in.

[Turbine D]

As I implied earlier, the legal profession tort process makes its living from peoples' inability to exercise perfect foresight.

It is relatively trivial to exercise perfect hindsight.

So very, very true!

First identify there is a problem... Wait and see seems to have been the drill. AF had (has) a leadership problem
and,
You could easily say this is all hindsight.

You are correct, it is hindsight. The analytical mind has great trouble retracting data that can be mostly recalled from memory while at the same time offering a should'a, could'a, would'a commentary.

Lyman
You're right - this is not hindsight but something which can be spotted in a professional and efficient organisation.

Yes it is hindsight and here is why!

You need to both go back and review the data presented in the BEA Interim report #2, starting on page 65. There you will learn there were indeed 9 events on Air France aircraft where loss of speed indication at high altitudes occurred. Seven events occurred between May 2008 and October 2008. All were on A-340 aircraft. You make it seem Air France sat on its hands and did nothing which was not the case at all. After the first event in May 2008, the second occurred in July 2008. Air France reported to Airbus the incident after the July 2008 occurrence and events thereafter. Air France then reported to Thale the worsening problem in October 2008. Then two new events occurred, one being the first one on an A330 aircraft. After ongoing discussions between parties including EASA, Air France on April 27, 2009 issued a modification to replace all pitot probes on all their long range A-340/A-330 aircraft with the first replacement batch of probes arriving a week or so before the AF447 accident. Review the tables of known events, at the time of the BEA report, starting on page 100 where at least 2 pitot tubes were blocked with ice.

So, which aircraft would receive priority in the change out of pitot tubes, the A-340 or the A-330? Wait, we can't answer this question without a bias of hindsight. Only the planners at Air France who developed the change out program can...

[Lyman]

Let's look at a parallel in the business world. NFL Football.

Highly skilled professionals are demanded to perform to maximum limits, and carry this mission through the year, no let up. Each "flight" occurs on one day/week, generally. The action is technical, physical, and mental. Post game, there is INTENSE forensic activity, by the professionals, their guidance team, (coaches) and to a lesser extent, support staff. The goal is to improve on an already excellent effort. Status quo effort gets people fired....

Films, interviews, comparisons, computer, medical, etc. It is ALL hindsight.

Without looking backward, there is total waste of effort v/v an improvement, perhaps in small increments, but without constant improvement, there is backsliding, into a "who cares" culture that gets ridiculed, and eventually swallowed up.

Competition in aviation is cutthroat, as it should be. The loss of safety goals from the competitive landscape is dangerous, for in aviation, losers don't just get released, sometimes they die, and take a portion of the audience with them.

I am trying my best to understand what is wrong with a look back? Is it because someone is looking who is from the outside? You cannot police yourselves, you are not well regulated by those who are entrusted to do so. Perhaps it is time for outsiders to see the evidence, examine, and make judgments?

Defending a system that is under attack is to be expected. It is possible we will never agree; I get the impression there is a stance of apologia here, based on the straw man of "hindsight bias".

Hindsight? Bias? So stipulated, then. Shall we move along to acceptance, and discussion, rather than wasteful attempts to de-certify?

TurbineD. I have run across doctored photographs purporting to be from IR2. May we PM?

[Organfreak]

Lyman wrote:

Let's look at a parallel in the business world. NFL Football.

Let's not and say we did.

Football is just a game.
Flying hundreds of people through the troposphere @600 MPH in a "tin can" is not a game; it's (can be) a deadly exercise.

Sometimes I feel like you must instruct us all, constantly, at length, with your ideas, as opposed to facts. I don't want to block anyone, but you wear me out, buddy! Chill?

[jcjeant]

Hi,

Turbine D
You need to both go back and review the data presented in the BEA Interim report #2, starting on page 65. There you will learn there were indeed 9 events on Air France aircraft where loss of speed indication at high altitudes occurred. Seven events occurred between May 2008 and October 2008. All were on A-340 aircraft. You make it seem Air France sat on its hands and did nothing which was not the case at all. After the first event in May 2008, the second occurred in July 2008. Air France reported to Airbus the incident after the July 2008 occurrence and events thereafter. Air France then reported to Thale the worsening problem in October 2008. Then two new events occurred, one being the first one on an A330 aircraft. After ongoing discussions between parties including EASA, Air France on April 27, 2009 issued a modification to replace all pitot probes on all their long range A-340/A-330 aircraft with the first replacement batch of probes arriving a week or so before the AF447 accident. Review the tables of known events, at the time of the BEA report, starting on page 100 where at least 2 pitot tubes were blocked with ice.AF .. Airbus ..EASA .. Thales .... even DGAC ..
One actor is missing ... the BEA
Where are inquiries .. investigations and reports (recommendations) of the BEA concerning all the pitots events (incidents) concerning french registered aircraft prior AF447 event ?

[OK465]

It's interesting that people are willing to pay a lot of money to sit in a seat that is not necessarily so comfortable, but is 'relatively' safe, at an NFL football game...and that as a result, an individual in a 'profession' which predominantly values sheer physicality over intelligence is rewarded with a handsome life style for doing nothing more than entertaining.

As contrasted to sitting in a relatively more comfortable seat, which is 'relatively' less safe...

I guess you get what you pay for.

[Lonewolf_50]

Points raised that got me thinking again:

Once aeroplane was back at FL350 indicated, there was no reason to pull anymore, yet he pulled and pulled and pulled, reaching an apogee of FL379, 2900 ft above cleared level. If there was a reason to keep pulling, it was not on altimeter anymore.
As before, the unanswerable "what was he seeing" during this time segment comes to mind.
The fact that a 5deg pitch isn't as harmful as a 15deg pitch-up is beside the point: Why pitch-up at all when in cruise flight just because the pilot considers that there is "immediate risk to the safety of the flight"? Where is the "immediate risk"? In my view, there is apparently far greater risk in destabilizing the airplane in cruise flight than in keeping it level, for troubleshooting. Thirty-odd other crews seem to have agreed with this view.
While all thirty of the other crews were not AF, what is the likelihood that all 30 or so events were shared and understood by crews at the time? Many no doubt were familiar with them via however safety reports and updates are distributed ... but how well understood? Probably unknowable.

Why destabilize a transport aircraft in cruise flight when a better course of action is to keep the pitch and power settings which existed prior to the failure?
IN the thread that alludes to "another 447 avoided" that same question can be asked, given the altitude excursion they experienced. Perhaps the crew in that incident has an answer?
What we do know from the CVR is that no normal/abnormal ops SOPs and no CRM procedures took place.
An AF training/cultural issue. (Could also be termed a standards and standardization issue).
After ongoing discussions between parties including EASA, Air France on April 27, 2009 issued a modification to replace all pitot probes on all their long range A-340/A-330 aircraft with the first replacement batch of probes arriving a week or so before the AF447 accident. Review the tables of known events, at the time of the BEA report, starting on page 100 where at least 2 pitot tubes were blocked with ice.
This hull was perhaps a few weeks away, maybe a few months away, from its tubes being replaced.

Ouch. :{

[HazelNuts39]

IN the thread that alludes to "another 447 avoided" that same question can be asked, given the altitude excursion they experienced. In the two 'level bust' incidents the zoom-climb was mostly automatic. In the AF incident the PNF in response to an overspeed warning accidentally disconnected the AP and gave a brief pitch-up input on the sidestick.

[Turbine D]

Hi jcjeant,
Where are inquiries .. investigations and reports (recommendations) of the BEA concerning all the pitots events (incidents) concerning french registered aircraft prior AF447 event ?

Perhaps the answer lies in the first paragraph of the BEA mission statements.
The BEA (Bureau d'Enquêtes et d'Analyses pour la sécurité de l'aviation civile) is the French authority responsible for carrying out safety investigations relating to accidents or serious incidents in civil aviation.

The statement pertains to French aviation investigations or international aviation investigations where French citizens are involved and where the BEA would be a participant in the investigation but not the leader.

In the instance of the pitot tube events, none of the nine, involving French airlines, were considered to be serious incidents or incidents that resulted in accidents requiring investigation, if I interpret correctly.

I am just reading from the BEA's mission on their English homepage.

[Shell Management]

Signs of a new scandel emerging. Three Years After Air France 447 Crash, A Hint of Scandal - Global - The Atlantic Wire (http://www.theatlanticwire.com/global/2012/06/three-years-after-air-france-447-crash-hint-scandal/53265/)
Perhaps CCTV should be fitted in rest areas.

[mm43]

Originally posted by Lonewolf50 ...
As before, the unanswerable "what was he seeing" during this time segment comes to mind.


see
think
react



input
compute
output

You can present the "triangle" in many forms, but you need to know conclusively two sides to ensure an understanding of the third.

The thousands of posts in many PPRuNe threads on the subject have traversed this fundamental triangle many times and from many angles, and all propositions inevitably involved guesstimates of at least one side and probably two. The BEA's final take on the same problem will most likely also fall into this great "unknown".

What bothers me most at this point, is the obvious disconnect between both co-pilots and their failure to observe SOPs in even an elementary form. So my conclusion is that this "disconnect" went beyond the confines of the cockpit and may well have involved all three of the flight deck crew.

Yes, just another triangle. :uhoh:

SM - Well, I wasn't referring to that, but if it helps solving the "problem", then use it.:}

[Lonewolf_50]

SM
Age: 64
Posts: 683
Couth: 0

Signs of a new scandel emerging. Three Years After Air France 447 Crash, A Hint of Scandal - Global - The Atlantic Wire (http://www.theatlanticwire.com/global/2012/06/three-years-after-air-france-447-crash-hint-scandal/53265/) Perhaps CCTV should be fitted in rest areas.

So long as you don't mind CCTV cameras being fitted to your private office, your home, your bedroom, your shower, and your lavatory ... not that anyone wants to watch you ... :p

@mm: well said, in re various triangles, but not the silly love triangle speculation dreamed up by some.

[Shell Management]

When I have 300 lives in my hands I'd have no objection.:ok:
No true proffesional would.

[jcjeant]

Hi,

SM
Age: 64
Posts: 683
Couth: 0
Quote:
Signs of a new scandel emerging. Three Years After Air France 447 Crash, A Hint of Scandal - Global - The Atlantic Wire (http://www.theatlanticwire.com/global/2012/06/three-years-after-air-france-447-crash-hint-scandal/53265/) Perhaps CCTV should be fitted in rest areas. Welcome back of the sleeping captain Dubois story .....

BEA report N°3 (plain english)
Between 1 h 59 min 32 and 2 h 01 min 46 , the Captain attended the briefing between the
two copilots, during which the PF said, in particular “the little bit of turbulence that you just saw
we should find the same ahead we’re in the cloud layer unfortunately we can’t climb much for
the moment because the temperature is falling more slowly than forecast” and that “the logon
with Dakar failed”. Then the Captain left the cockpit.

At around 2 h 11 min 45 , the Captain re-entered the cockpit. During the following seconds,
all of the recorded speeds became invalid and the stall warning stopped. 2 h 11 min 45 - 2 h 01 min 46
Do your maths .....
10 minutes .....
Call me whatever you want .. but my opinion is that the back of the captain never touched the bed sack and the captain never closed his eyes ......
ZZZZZzzzzzzzzz :=

[wiggy]

From the "report"

The captain, Marc Dubois, who was on a scheduled break when the plane hit heavy weather and the autopilot disengaged, took more than a minute to respond to the crew's calls for help.

"more than a minute" :eek: I'm shocked, I really am :uhoh:....

Think about it - everyone the most mighty skygod, requires a few seconds to wake up, especially if they've gone off into a deep sleep....and most of us don't sleep in the uniform ( creased uniform is bad for the company's image, as is running to the flight deck in your shreddies, don't you know :bored:) Most of the time on a flight with a "heavy" you're lucky to get a resting crewmember(s) back onto the flightdeck in under 5 minutes from initiating a wake up call. You can run all the love triangle and conspiracy theories you want but we all know (don't we?) that it takes time to wake up and be aware of one's surroundings - I can't see how putting TV cameras in the bunk area is going to solve that particular human factors' "problem", but nevertheless I see the usual suspect has declared him/herself as a fan of the idea .....

10 minutes .....
Call me whatever you want .. but my opinion is that the back of the captain never touched the bed sack and the captain never closed his eyes ......


FWIW since I was utterly cream crackered somewhere over the Far East last night it took me less than ten minutes from seat to a very deep sleep j.c. , so my opinion is that yes, it certainly can be done.

[jcjeant]

Hi,

wiggy
FWIW since I was utterly cream crackered somewhere over the Far East last night You maybe .. what was your rest time before the flight .. how much time you had flying
Remember that captain Dubois had many many hours (days) for rest in Rio and he was not from looong time on flying AF447 on the return segment ....
Other:
I just finished watching the video of the Nightline program and Mr. Troadec (BEA chief) does not seem very at ease to answer certain questions or makes a dodge with a smile that speaks volumes
He was more at ease during his meetings in France
But journalists did not asked him the same questions

[chrisN]

If he was attending to a call of nature, getting back to the cockpit in a minute from when called is actually quite quick.


Chris N

[wiggy]

ChrisN

Agreed.


j.c.

You maybe .. what was your rest time before the flight .. how much time you had flying
Remember that captain Dubois had many many hours (days) for rest in Rio and he was not from looong time on flying AF447 on the return segment

It doesn't much rest he (or I for that matter) was rostered to have had. In an ideal world (the sort of world the regulators live in) after a multiday slip you will be well rested, but we all know that sometimes you're not at all rested. You've maybe had bad sleep, had your sleep disturbed by the party out by the hotel pool or the couple in the next room :ooh:.

In heavy crew ops as a captain, IMHO, you are entitled to think that your colleagues on the flight deck can action, at the very least, the initial items a non-normal checklist, and contain a problem long enough for you to get dressed and return to the flight deck. If (note, I say "if") that wasn't the case on AF447 then the problem lies with AF's procedures, training and checking of junior crewmembers, not with captain Dubois sleeping arrangements.

[Old Carthusian]

Turbine D
I would argue that what we are doing is very definitely not 'hindsight'. To my mind the question with hindsight is 'could the actions taken in the past have been avoided with the knowledge available at the time?' If the answer is yes then the discussion is 'looking back' not hindsight. If the answer is no then the discussion is hindsight.

Leaving aside the issue of Air France and it's part in this accident if we ask whether the crew could have avoided the accident using knowledge that they could have reasonably expected to possess or have access to we reach an answer of yes they could. Why they didn't is part of finding out why the accident happened. A lack of any evidence that the correct procedures were followed leads one to think that things went very badly wrong but this is not hindsight. As I understand Airline training and practice it is based on following these and thus one would expect such practices and procedures to be followed in all cases. Once again this isn't hindsight but just an expectation that the already designed processes will be followed.

One can say that Air France should have expedited the replacement of the pitot tubes and this accident wouldn't have happened. This would be hindsight given that non of the incidents had led to anything resembling AF447. A situation existed which needed change but one could argue that this accident could not have been anticipated. However, if we were to say that the crew should have responded to this situation in a different way this is not hindsight. This is just an expectation based on a reasonable supposition that the crew was properly trained and conversant with the procedures for successfully operating a large transport aircraft. We trust airline professionals to reach a certain standard and ability. We may not expect them to be supermen/women but we do expect a certain level and the vast majority to conform to our expectations.
OC

[Turbine D]

OC,

Thanks for your response.

One can say that Air France should have expedited the replacement of the pitot tubes and this accident wouldn't have happened. This would be hindsight given that non of the incidents had led to anything resembling AF447. A situation existed which needed change but one could argue that this accident could not have been anticipated.

Your quote is exactly what I meant by hindsight. I limited my post only to the pitot tube situation, leaving what the AF447 crew did or didn't do up to those have flown or presently fly commercial jet aircraft.

[chrisN]

OC, “if we ask whether the crew could have avoided the accident using knowledge that they could have reasonably expected to possess or have access to we reach an answer of yes they could.”

Do you think that they could have been reasonably expected to possess or have access to: manual flying expertise at FL350; and an appropriate UAS SOP at FL350?

(Not that these were the only factors in their inappropriate reaction to events – just some which seem to me and some others to exceed what might be expected, in view of the industry standard training in general from what I have deduced from these threads, and about AF training in particular.)

I think that SLF, regulators in principle, and MPs and the public, might have such reasonable expectations; but reading the difference between old-time pilots who grew up in a different era, and the modern 250-hour computer management “children of the magenta line”, do insiders believe it to be a reasonable expectation given the latter’s background?

[Old Carthusian]

chrisN
I am a general aviation pilot (biplanes, biplanes, biplanes) so I hope you will forgive me if my suppositions are wrong. I always understood it that modern civil airliners flew with a set of SOPs on board in the cockpit, immediately available for the crew to use. I also understood that airline training involved the use of SOPs and CRM to identify and troubleshoot issues that might come up. As for manual flying skills I agree with your last paragraph and I wasn't referencing these. I would suggest though that some form of manual flying skill is essential and to be expected - for any pilot.

[alf5071h]

OC re #1169. You appear to assume that because knowledge exits it can be recalled for use at any time, or that all situations will be understood (as you would understand them). Hindsight bias is within these assumptions.
Without detailed evidence we do not know what the crew thought – what was or was not recalled from memory, or how it was used in their assessment; similarly what they deduced about the situation and events.

The human mind has a natural tendency to ‘join-up the dots’ to create a familiar picture; – our understanding of the world as we would wish it to be. In order to learn from difficult accidents such as AF447 we have to restrain this tendency and only work with what we know factually.

There is much which we might learn from hypothetical speculation, by attempting to understand what the crew might have seen, thought, or decided. In this it is essential that our thinking is tightly controlled and that we do not form erroneous conclusions due to hindsight.
We might identify what physically happened; and with considered judgement it may be possible to identify contributing factors which could have influenced the crew, but without any assurance of proof.
In these circumstances the safety lessons to be learned come from questioning how we might see, think, or decide when faced by the contributing factors, e.g. as a start, would we have identified the situation as requiring reference to the UAS drill – why? Ask why 5 times, without knowledge of AF447 outcome.


Chris N, whilst it might be reasonable for MPs and the public (SLF) to have their expectations, those of the regulator and industry should be kerbed by the facts, and knowledge and application of human factors.
If, or when public judgement is required, then hopefully legal judgement would caution about hindsight bias. However, this is becoming a very disturbing area of aviation which requires both public (media) and industry restraint, supported with simple education of human factors to dampen expectations.

[Old Carthusian]

alf5071h
The issue here would be whether the knowledge available could be expected to be used by the individuals concerned and whether it was indeed provided for that purpose. Furthermore, one could ask whether the training is provided teach them about use of such knowledge. The answer to all these questions is yes. It is a reasonable expectation that a pilot of an airliner is familiar with his machine and knows how to access troubleshooting and analysis procedures. There are after all certain standards which must be maintained.

This is not hindsight or even linked with it. We know that the crew did not use the SOPs from the transcript of the CVR but we also know that airline training is based on use of these tools which are easily accessible. This also is not hindsight - the processes and systems are built on this usage. If (to hypothesise) the SOPs were not meant to be used by crew members then of course any statement that they should have used them would represent hindsight. This I do not think is the case - the SOPs are there to be used by flight crews and therefore to not use them is a demonstration of an incorrect response to the situation. This is fact - it is not hindsight.

[Machinbird]

We might identify what physically happened; and with considered judgement it may be possible to identify contributing factors which could have influenced the crew, but without any assurance of proof.
One thing that demonstrably took much of PF's attention during the first 35 seconds after the AP drop was the very significant roll oscillation and the method used by PF to control the oscillation. (He had apparently never seen Alt2 law at altitude.)

If you look at the periodicity of the oscillation, and of the roll control inputs, his control inputs accelerated (in an apparent attempt to get ahead of the oscillation.) His inputs did not cease although the aircraft momentarily stopped roll oscillating on approximately 3 occasions, and these continued inputs caused a phase shift in the roll oscillation-based upon my analysis. This type of control input indicates formation of a control strategy, and correction of the control strategy. Clearly, a significant portion of his attention was devoted to the early roll control problem.

[PJ2]

OC;
I would suggest though that some form of manual flying skill is essential and to be expected - for any pilot.
Some observations, for what it's worth...

I couldnt' get a single F/O to hand-fly the A320 or the A340/A330 when I offered (and in some cases asked them to fly). Primarily they were afraid of the thrust levers, (disconnecting them, controlling thrust etc) but for whatever other reason they just didn't want to actually hand-fly. I always thought flying a visual was both challenging and about all we have left to us to practise that part of our craft that was being discouraged, but I was told by my F/Os that a lot of captains refused the request to hand-fly because they themselves were uncomfortable disconnecting and it increased the workload on the PM. The PM set all the autoflight windows...the headings/altitudes and programmed the FMC when needed (which was heads-down of course), and kept a watch (there was usually a third pilot, an RP, in the cockpit...hand-flying was discouraged by the company except in low traffic density airports...yeah, right...low density international destinations) and when there was an "event" associated with hand-flying, they tightened the rules even more. We used to do it all the time on the DC8's/9's B727's, Lockheeds even the B767's but airlines want the automation used and now navigation procedures (RNP, STARS, SIDS) make autoflight necessary. The loss of skills, both handling and thinking, is a vicious circle process.

Now before we assume too much in this, the actual hand-flying the airplane isn't much of a challenge...trim is done for you, thrust is automatic and the autopilot is (depending upon the "hands"), smoother. In fact while hand-flying isn't much of a pilot's challenge, its more of an interesting challenge to make the autoflight work well. What's lost is the thinking skills when you have your hands on the controls....it's different than programming and flying through the Mode Control Panel; You're "connected" to the airplane.

I always felt I had good reason to trust the guys up front when I went back for the break. Still, as a rule I didn't go back went during the ITCZ crossing, "just because". It wasn't because of the hand-flying issue...to be blunt, I just didn't know what kind of radar skills everyone had.

At the time, I'd never heard of such a thing as "UAS" and losing the airspeed data at altitude, (1999 - 2007 on the 340/330). It was just never discussed or demonstrated.

I don't know what the answer is. Automation has become necessary, not just nice to have. But handling skills (which form thinking skills and a proper scan in my books) need to be re-introduced, taught and reinforced with practise. It wasn't in the script, but I can recall one sim in particular where the check captain made us do climbing then descending S-turns while changing speed. Every skill was practised...including the instrument scan.

[john_tullamarine]

climbing then descending S-turns while changing speed.

Such or similar fun used to be a standard first endorsement sim exercise to give the trainee a feel for the machine.

My favourite was to start S&L on a heading and then enter a steady climbing turn to arrive on the same heading, 1000 ft higher while increasing steadily to 30kt faster ... and then do the same on the way back down. Then repeat, this time losing the speed increments.

Got the eyeballs and thinking cells active.

Then, interspersed through the routine session stuff of the endorsement, get the trainee up to being able to hand fly, raw data, an ILS in 0/0 to a stop on the centreline. Very much confidence building and the I/F stick and rudder skills skyrocketed.

[Machinbird]

Such or similar fun used to be a standard first endorsement sim exercise to give the trainee a feel for the machine. This was standard fare when I went through as a student and much later when I instructed in the Navy advanced jet program. We called the exercises Basic Instrument exercises because they formed the foundation for the rest of instrument flying. Mostly we used the S patterns, primarily S-2 and S-3 patterns involving standard rate turns combined with standard climb/descent rates at constant airspeed.

If the training aircraft had an autopilot, they were not maintained/not used and it was strictly a manual exercise.

Are modern day pilots still being taught to hand fly such exercises at any stage in their training?

[CONF iture]

between 02:10:05 and 02:10:07 FD2! (RH PFD) was not engaged.
FD1 was continuously displayed and FD2 was missing for a split second. The low resolution of the published data do not allow to tell more.

IMO FD bar position would have been ND and minor.
I disagree on that.
What was displayed in the FMA as a vertical mode ?
Where is the FD/AP vertical mode trace ?

It will be a major blow if the FD behavior is not extensively covered in the coming BEA final report ...

[CONF iture]

It will never stall an aeroplane as long as there is sufficient power available. With 5° pitch maintained, aeroplane climbs, power drops, AoA goes up until level-off at 5° alpha is achieved. Any aeroplane.
It sure brings you to the stall warning. That's flying on the edge with no necessity. What's the point when usual pitch and thrust for cruise is the answer.
Airbus has it wrong on that one, even its chief pilot says differently now.

[PJ2]

Machinbird;
Are modern day pilots still being taught to hand fly such exercises at any stage in their training?
No, not to my knowledge and I keep in touch as best I can.

John T.
Very much confidence building and the I/F stick and rudder skills skyrocketed.
And it needn't be a drawn-out thing. Both pilots can get some practise in, in half-an-hour and carry on with the rest of the script. It's not difficult, doesn't require Congress to be involved in any new FAA regs and as you say, builds tremendous confidence. It was the most frustrating thing, to watch guys give up the opportunity to fly no matter what I said I'd help with. It's not difficult stuff but you can lose the touch and overcontrol quite easily, (seen it in the sim). What happened with the roll isn't serious but perhaps the PF didn't know that. I think that's all that happened with the PF trying to get the little bit of roll under control - don't stir the porridge...just set the stick in one position and hold it, wait for the massive machine to settle down, then tiny movements...But if you don't have the touch due to lack of training and experience, confidence in your solutions in trying to bring the airplane back with the stick can erode very quickly if you see yourself making a hash of things. It isn't complicated - it's what we used to routinely do.

[RetiredF4]

Machinbird
This was standard fare when I went through as a student and much later when I instructed in the Navy advanced jet program. We called the exercises Basic Instrument exercises because they formed the foundation for the rest of instrument flying. Mostly we used the S patterns, primarily S-2 and S-3 patterns involving standard rate turns combined with standard climb/descent rates at constant airspeed.

A similar maneuver, but with changing speeds.

Lazy 8 (http://avstop.com/ac/flighttrainghandbook/lazy8.html)

@PJ2 Your relevation is frankly speaking "shocking".

[PJ2]

RetiredF4;
@PJ2 Your relevation is frankly speaking "shocking".
Well, this is just one pilot's/captain's experience - others can speak out if they wish. For me, I really, really encouraged guys/gals to hand-fly including manual thrust levers and there were almost 100% no takers. When doing line indoctrination I taught manual flight, what to be aware of when disconnecting the autothrust, how Bangalore (http://aviation-safety.net/database/record.php?id=19900214-2) happened (the software's changed since then) and so on. I've only been a captain on Airbus aircraft. I hand-flew all the other types I was on but so did the captains, because we were better than the automation and it was, frankly, (serious) fun.

I think the Airbus is as easy and straightforward to hand-fly as any other type I've been on. The source of the "mystique" and therefore the fear of disconnecting and hand-flying is, in my view, twofold - 1) the airplane is complex with many modes including the autothrust, and 2) transition training and recurrent training focus competence and facility with the autoflight system and took competency at hand-flying (including thrust management) for granted.

The first time I did a proficiency check and IFR ride on the A320 it was entirely on the autopilot to demonstrate knowledge and understanding of the system. It felt really strange and it felt like I was somehow cheating and not demonstrating what I knew, (because with work, the autoflight systems aren't difficult to understand, remember and use).

Subsequent recurrent training sessions worked in a manually-flown approach on raw data and we'd also do steep turns. I never saw the "S-turns" exercise again and I'll bet these days most would find it very difficult to complete.

In steep turns, autothrust was left on and we used the bird, (FPV symbol) for steep turns. It was a piece of cake...for the autoflight. All that was necessary was to keep the FPV on the horizon. Looking back, with autotrim it wasn't really a test for handling skills in my opinion. Cognitive connection to the machine reduced because of this, I believe.

I hand-flew all previous types and so did the captains I flew with. For the A320 I often flew from top-of-descent to touchdown and the airplane was a joy to fly manually. I did the same for the A330/A340 into terminals such as Hong Kong, Narita, Sydney, London, (after we were handed off to the final approach controller and out of the hold!), Frankfurt on the downwind, Honolulu, the Caribbean.

Towards the end I gradually stopped hand-flying this way, not because the SIDS and STARS got too demanding but because I began to realize that if anything were to occur during hand-flying, the first thing they'd look at would be the fact that the automation wasn't engaged and I'd have some explaining to do. I think that is the wrong approach, but...before we come to a black-and-white conclusion that this is all bad, I think there is good reason on the part of airline managements to require the use of automation and to teach/train/instruct thoroughly on its use, abuse and failure modes. They are doing what they think is best in terms of risk management in an increasingly busy airspace and terminal environment.

That said, when an approach incident occurred, hand-flying was increasingly discouraged Formal policies which provide guidance as to when one can do it, (low traffic volume/low work load for the other pilot etc) helped but the policies effectively prohibited hand-flying because entering non-busy terminals, especially on international routes, simply doesn't happen.

I think the vicious circle has been complete for about a decade now where discouraging hand-flying has indeed resulted in a loss of those important but invisible skills: instrument scan while busy, smooth, anticipatory manual handling of the aircraft and engine thrust...in short, "energy management" (and therefore fuel cost management) and crew coordination during manual flying conditions...the change is subtle but material to effectively and safely piloting the airplane.

The routine was established in the 90's - the autoflight was engaged right after the last flap/slat retraction and disconnected at about 400ft on approach at destination. There is NO opportunity for practise under such conditions but guys realized that the airline wanted the autoflight engaged and most didn't argue. I think they should have, as pilot associations should have, but that is a personal view.

This isn't a sudden, unexpected, surprising state of affairs. In one of the many, many AOM changes we experienced came the admonition that "the autoflight WILL be engaged right after takeoff and disengaged on the landing roll". Aside from the fact that many of our approaches in the A320 were NPAs and couldn't be an autoland, the short-sightedness of such an airline policy was fought very hard and we won the freedom to hand-fly the airplane under an "automation policy". It was a step in the right direction but there was no formal acknowledgement that training was required and so the focus on autoflight comptetency remained and one hand-flew if one wished but it wasn't supported. I don't think we were unusual. We may be surprised and shocked but that's the way it was and, I suspect, is today.

These notions have been expressed since the mid/late eighties almost exclusively from pilots transitioning to fully-automated aircraft. The original reason pilots didn't want to hand-fly was because, "What's it doing now?" was a real question in the early 90's. "Click-click", (autopilot/autothrust OFF) was the solution until one sorted oneself out but pilots are primarily problem-solvers and sometimes will try to fix the problem (how do I get the OFFSET Page?...how do I get a hold entered again?), instead of changing horses and disconnecting while sorting it out. It's a cognitive thing, not a technical thing. It's why I keep saying that the UAS item shouldn't have been a problem...it's just straight manual flight, keeping it level and keeping thrust while the other guy/gal gets out the books. No big deal. Really.

So now we have to sort out why this one became a big deal and ended in an accident and in the eight or nine threads we've had a good go at it. Those here who are pilots know that this kind of thinking isn't unique, it's "what is". Nor am I alone in knowing that the solutions are comfort with the machine in all its normal and abnormal regimes and phases, and that the job of training (the company) and the job of learning (the individual pilot) isn't finished until that comfort is there. It isn't about notions like efficiency, cost-control or shortened training footprints, it's about pilots being familiar and therefore comfortable in their machine, no matter what it costs or how long it extends the training footprint. And it doesn't take tens of thousands of hours in a career, or weeks added onto the normal training footprint to achieve this comfort - it takes work, mainly on the part of the pilot, but also on the part of the airline in providing a supportive, comprehending management approach to foster this level of comfort.

In my view, the answers to AF447 are in one way not complicated. But these notions certainly are not "provable" in the traditional ways we are accustomed to accepting "evidence". There is no recorder that can record confusion, fear, competency or lack thereof. We must come to those conclusions, if possible, obviously by other means and these days, when Cartesian thinking invisibly rules (and narrows) our assessments of "evidence", we can miss some processes that may be relevant to the accident. The above "stream" tries to deal with this.

Getting this off my chest...sorry for the thread drift.

[Organfreak]

PJ2,
Thanks (again) for your erudite and informative post.

IMHO, if THE FLYING PUBLIC, not only those "in the know," were to be made fully aware of this situation (never an easy proposition), the effect on the industry would be devastating. 'Twould be a huge scandal.

Speaking as a self-elected representative for SLF everywhere, being flown by "pilots" who CAN'T FLY THE AIRPLANE is absolutely, unconditionally UNACCEPTABLE. As discussed earlier, having pilots who can hand-fly the pane in a pickle is not only a reasonable expectation of every passenger, but must be mandatory.

I, too am shocked that this is even controversial at all. I don't care HOW much it costs the airlines-- this has to change, in the grim and bloody light of AF 447. If it doesn't, there will be more tragedies of this kind until it is fixed.

:eek:

[PJ2]

Organfreak;

Caution is advised in interpreting these remarks.

The industry's record speaks for itself and it is a superb record overall.

It is critical to an understanding of these remarks that they emerge from and dwell within a context of significant and even spectacular success. They do not portray an industry "coming apart at the seams" about which we must then ride off in all directions regarding skies and the falling thereof. Rather, if I may, these remarks represent a distillation of ongoing issues which have been "in process" for many years and with which most pilots and certainly all safety specialists are familiar. We know that the character of accidents is changing. Many interested parties will interpret these changes in terms of their own specialties, which is a good thing because nobody is capable of seeing and then communicating well, the whole picture, while keeping in mind the industry's successful record and extremely safe state of affairs.

This is pretty open stuff. Our industry is, because of its high-risk nature, pretty open itself because we value learning and prevention of untoward trends and events, above all.

No other industry or endeavour demonstrates this willingness quite so strongly and so such frankness requires a reserved and contemplative approach. These are not sudden trends or sudden events. We should be even more willing to discuss some of the less attractive aspects of the business but over-reaction is what stops many. Yes, there are always politics involved; -we need only take a look at what is happening in Nigeria (http://www.bloomberg.com/news/2012-06-07/why-nigeria-plane-lost-power-before-crash-still-mystery.html)* at the moment to know that there remains an enormous misunderstanding about how our industry makes itself so safe.

These kinds of things discussed in the post must be taken with some forebearance and perspective - millions and millions of hours of safe and unremarkable passenger transport, decade after decade. Such events as AF447 are vanishingly-rare. Whether perfection is achievable or not is not the quest - the attempt is what examination of these aspects of our industry is about.

Such frankness and openess can result in a form of "autoimmune" disease, if you will. The very characteristics of frankness and a willingness to look at the nasty bits, all of which make our aviation transportation system safe, (our "immune system") also at the very same moment in time, has the capacity to damage or even destroy that which makes it so safe.

In short, that which makes us successful also equally has the power to harm. The key to our industry's health (and therefore its continuing high levels of safety) is in how "the immune system" is treated.



*Nigeria’s chief aviation regulator, recommended for suspension after the nation’s deadliest accident in almost 40 years, defended his record as several safety advocates said he may become a scapegoat.
“Would you please wait for the accident investigation to complete, to have seen the black boxes, before we start judging?” Harold Demuren, director general of the Nigerian Civil Aviation Authority, asked in a phone interview yesterday.

Demuren appealed for patience during the investigation into the Dana Airlines Ltd. crash on June 3. All 153 people on board and an unknown number on the ground were killed when the Boeing Co. (BA) MD-83 jetliner crashed and burst into flames in a Lagos suburb while approaching the airport on a domestic flight.

Nigeria’s aviation industry had one of the world’s worst safety records in 2006, a year after Demuren took his job. Four years later, the U.S. Federal Aviation Administration gave Africa’s largest oil producer a Category 1 rating, which allowed its domestic carriers to fly to the U.S.

“We have become one of the safest places in Africa,” Demuren said, speaking from Nigeria.

Nigeria’s Senate voted June 5 to recommend that Demuren be suspended. The minister of aviation, Princess Stella Adaeze Oduah, will convene a panel June 11 to review the nation’s

[RetiredF4]

Thank you very much for your open words.

A friend of mine, also a retired Phantom driver, flew the A320 until final retirement 2 years ago. On the few occasions we were able to talk about flying the bus he was happy with the manual handling qualities, he always told me "franzl, you wouls have loved that plane". In the same moments he was telling the stories about FO´s unwilling to handfly the plane except for T/O and Land, and in more than one occasion he was reported up the chain for doing so.

Well, i didn´t believe everything he said, and your post sheds a different view to his narratives.

My nephew got accepted by LH to become a pilot last month, he is very happy about it. I myself was and am not sure, wether i should slap his shoulder for well done or wether i should caution him on being alert not to get a kid of the magenta line.

[CONF iture]

Getting this off my chest...sorry for the thread drift.
Not a thread drift at all, but I am surprised you did not mention the FD at all ... !?

Manually flying the 330 with A/THR + FD has nothing to do with manually flying.
It's only when FD is missing on the PFD that one can realize how much mental work is needed to keep things straight.

You told us how little manual flying is done these days, how much of that little is done without FD guidance ...

For AF447, as FD were not selected OFF, they keep coming back, the PF did not doubt them and was probably too happy to put his faith in them.

[Turbine D]

Hi everyone,

Interesting posts on the Humbling sim experience thread...

[IcePack]

It isn't about notions like efficiency, cost-control or shortened training footprints, it's about pilots being familiar and therefore comfortable in their machine, no matter what it costs or how long it extends the training footprint. And it doesn't take tens of thousands of hours in a career, or weeks added onto the normal training footprint to achieve this comfort - it takes work, mainly on the part of the pilot, but also on the part of the airline in providing a supportive, comprehending management approach to foster this level of comfort.

Well said PJ, training to confidence is what it should be..
Unfortunately the bean counters (think reduced training time) & the regulators think testing testing is the way to go, but then they will not be in the smoking hole and can always go and get another job.
:mad:

[Clandestino]

The drill was indeed viewed as obligatory as far as the BEA was concerned (in their press conference) and as far as many on this board were/are concerned. Actually, I was of the same opinion as I misread the 3rd interim; I believed that drill in QRH/FCOM stipulates memory attitudes while "if safety of the flight is affected" decision point is mentioned only in FCTM. Guess what: I was wrong.

By the time AF447 made its final flight I already left A320 and I have never worked for Air France. Our unreliable airspeed on 19/20 was very, very similar to AF on 30 with one very significant difference: there was no option to consider whether to apply memory items or to maintain cruise thrust/pitch. Legally, if I ever got to UAS, I had to apply 5° pitch above FL100 while PNF gets the weight/power/pitch tables out. Outcome-wise, it would not make a lot of difference if I would have set it or kept the things as they were.

Why pitch-up at all when in cruise flight just because the pilot considers that there is "immediate risk to the safety of the flight"?

(...)

Regardless, the main point I have always made and which you continue to miss is, Why destabilize a transport aircraft in cruise flight when a better course of action is to keep the pitch and power settings which existed prior to the failure?Perhaps because those who wrote the checklist did not believe the pilots' capability to remember the typical cruise attitude and N1 for different weights? 5° with CLB works for any weight until level-off values are read from table and set.

It sure brings you to the stall warning. That's flying on the edge with no necessity. What's the point when usual pitch and thrust for cruise is the answer.
Airbus has it wrong on that one, even its chief pilot says differently now. Let me list some of the ways in which this statement is wrong. 1. pulling can lead to high-mach-low-threshold transient stall warning if aeroplane is jerked into climb, reasonably smooth pull from about 1.5 to 5° will avoid it 2. when settled at 5° pitch, AoA will be near cruise pitch and will gently increase towards 5° as speed is bled off. By the time it gets there, you won't be at high mach anymore. 3. If no valid mach, stall warning reverts to low threshold 4. stall warning is not stall itself - a fact cheerfully ignored by those unable to tell the difference between "approach to stall recovery" and "stall recovery". 5. when arguing about Habsheim showoff, you repeatedly claimed that alpha prot prevented aeroplane from achieving higher lift at even higher AoA (backside of the power curve, anyone?) and now all of a sudden, stall warning is considered to be the edge? Are you having it both ways or are you about to make a breakthrough in aerodynamics - discovery of the area of fantastic aerodynamic performance between alpha max and stall warning? Besides, it would add some credibility to the statement of yours if you could provide quote of Airbus chief pilot.

I have long posited the notion that perhaps the pitch-up was due to a remembered response in training, right after takeoff, of the UAS memory itemsDon't you think if he was really trying to go for 15° pitch, he would have gone for it all of the time speed was not available? By the time second stall warning went off, left speed readout was normal. By the time aeroplane departed envelope, it was consistent with ISIS. No one checked it.

We actually don't know if the PF was applying this procedure or not as his actions were never announced nor was the PNF included in what was happening as the PFs actions took place. From CVR we know he never announced what he was doing. Form DFDR we know we know his actions were totally inconsistent with UAS procedure. What else do we need to know?

Hey Clandestino, we are talking about trained pilots, not random guys you pick up on the street.When I'm talking about Yuri Gagarin succumbing to spiral dive in cloud or Charles Basset and Elliot See perishing in controlled flight into building, I'm talking about astronauts, not some random airline pilots.

The only emotion an actual pilot might experience should be surprise. If any of the other emotions are being experienced, then that person doesn't belong in a cockpit without further training to convert those negative emotions into positive and considered action.Good example of "Invulnerability" risky attitude of which every CRM course warns one about, even the bad ones.

Pilots must have far, far better emotional stability than general public, however it can not be absolute. Emotions do affect the pilots' performance and everyone can break down, given enough pressure. Trick is having the breaking point in the area which is extremely unlikely to be encountered in flight. Can this be achieved through training? I don't know.

Flying is not supposed to have a lot of emotion attached to it other than appreciation for the beauties of the sky and the earth.Of course. Going emotional while flying will make one revert to basic instincts developed during millenia of terrestrial existence, which are sure to be wrong in the air and most probably fatal. Air is a rewarding mistress yet she is very demanding and impartial. If one doesn't abide by her laws every millisecond he's airborne, he'll get rejected promptly no matter if he's a newbie or an old acquaintance. Unlike pigeons, we don't have the flying skills in our DNA, it takes ability and devotion to etch them on the very surface of our cerebral cortex - the first thing to shut down when emotions run high.

Previous A330 ice crystal / ADC / ASI events may have concluded that flight into such conditions was an acceptable risk because of the non-fatal outcomes (with hindsight). Not just that, lot of them were not even detected until AF447 post-mortem uncovered them by sifting through QAR data. Pilots were so unfazed that they didn't even make reports.

To progress safety the industry requires to take a more abstract view for continued airworthiness (systems thinking), vice the probabilistic based certification viewYes, if we apply selective and very narrow hindsight. Every aeroplane type has dozens if not hundreds technical issues being investigated simultaneously. How can you determine which is minor, which major and which will turn out to be lethal if left unchecked long enough? Before AF447 it seemed that UAS is somewhere in the middle of the seriousness scale as pilots have successfully coped with it. There was no rush to change the offending pitots.

As before, the unanswerable "what was he seeing" during this time segment comes to mind.There will certainly be proposals for improvement of flight recorders, however, what his eyes saw will be pretty straightforward to decipher. What he believed he was seeing, not so.

what is the likelihood that all 30 or so events were shared and understood by crews at the time?Nil. Even worse: four crews that passed through ordeal did not recognize they have unreliable airspeed at all. Two were undecided whether it was UAS or not.

One thing that demonstrably took much of PF's attention during the first 35 seconds after the AP drop was the very significant roll oscillation and the method used by PF to control the oscillation.
Roll oscillation before stall was of low frequency, low and decreasing amplitude. It spells: insignificant and irrelevant. After stall all bets regarding roll control are off, unless you happen to fly some extremely aerobatic aeroplane, which A330 is not. Even if notion that preoccupation with roll precluded control in pitch were true, pilot unable to control the aeroplane around two axes simultaneously is severely incapacitated.

It isn't about notions like efficiency, cost-control or shortened training footprints, it's about pilots being familiar and therefore comfortable in their machine, no matter what it costs or how long it extends the training footprint. And it doesn't take tens of thousands of hours in a career, or weeks added onto the normal training footprint to achieve this comfort - it takes work, mainly on the part of the pilot, but also on the part of the airline in providing a supportive, comprehending management approach to foster this level of comfort. Fully correct. However, the fact that many more crews handled the situation in which aeroplane was thrown in their laps at altitude than not, will be used by those whose agenda involves playing the blame game by moving the focus from organizations to dead pilots.

Then, interspersed through the routine session stuff of the endorsement, get the trainee up to being able to hand fly, raw data, an ILS in 0/0 to a stop on the centreline. Very much confidence building and the I/F stick and rudder skills skyrocketed. I was lucky that my head of training, while I was working on my CPL, was a fellow who made it from gliding through cropdusting and night mail to position of chief pilot on DC10 fleet, only to have his career cut short by the flag carrier he worked in going down in flames, together with the country it served. He understood instrument flying very well, we started I/F training on FNPT with basic attitude+power, eventually progressing to VDF approaches, PAR approaches, ILS to stop on runway, UA recovery on partial panel, culminating on recovery with just vario and magnetic compass working. He was very keen to make us understand that while what we learnt might save us one day when situation gets really desperate, we are not supposed to get overconfident and paint ourselves in corner e.g. just because you can hold perfect raw data ILS below 200 ft QFE doesn't mean you should.

I would have expected Flight Standards Management (not just AF, but any operator of the Type) to have put a small sample of line pilots into the simulator to observe what their responses might have been to such events ? The outcome of such an experiment might then have suggested whatever when it comes to training program variations. I don't think it would be much of use. It might uncover a pilot or two too lazy to know memory items or recognize what procedure to apply when the ECAM crutch gets broken but a pilot who is fully aware "it's only a simulator" and only on the dark, stormy night is fully hit with the realization that air is not a friend and that his life is at stake every time wheels leave the ground would slip under the radar.

[alf5071h]

OC, re #1174, I agree with your thoughts on expectation, but any conclusion that the crew should have followed a specific drill (SOP), because it was the obvious course of action, involves hindsight bias.
It is not the physical presence of a drill which is important; it is the mental process which decides to use it. We can establish the presence of a drill and associated training, but not what the crew thought, or what might have influenced their thinking – the effectiveness of the drill / training.

“…the SOPs are there to be used by flight crews …” yes, but when the crew has understood the situation as requiring that specific drill, and thus the drill is selected. Inferring that this is obvious judges the crew’s awareness and decision making after the fact – this is hindsight bias.
“… and therefore to not use them is a demonstration of an incorrect response to the situation”, yes this is one possible hypothesis, another is that the crew did not understand the situation and thus ‘chose’ not to use the drill – it never occurred to them (see ref).
We can construct many hypotheses from the information gathered after the fact, which can be used as valuable tools for investigation and safety response, but instantly a hypothesis is taken as ‘fact’ without evidence, this involves hindsight bias.

In this instance, the bias is our assumption that the crew understood the situation as involving UAS, and thus did not follow the appropriate drill.
It is just as plausible that the crew’s actions were entirely consistent with the situation as they saw it; but we don’t know what that was and currently can only speculate on a rage of alternatives.

Unfortunately, the vast majority of the thread discussion is based on a biased starting point, although to be fair some contributions have qualified their points as hypothetical.
There may be some significant safety issues arising from these hypothetical explorations, particularly in the process of awareness in the first few seconds of the event (not the subsequent and more salient stall condition – which also the crew may have not been aware of).

Some significant contributors have been identified:-
UAS drill formulation; is the title relevant, will the crew know when to select it. These are issues of procedure formulation and industry wide communication.
How to identify UAS situations (involving system malfunction): what are the key features, were these explained in training and associated with the range of recovery procedures. These are training issues, but also aspects of memory and recall in context.
Human behaviour in sudden and surprising events; what might effect perception and choice of action, - Human Factors.
Are these a source of the problem or a solution?

Errors in Aviation Decision Making, Orasanu & Martin. (www.dcs.gla.ac.uk/~johnson/papers/seattle_hessd/judithlynne-p.pdf)

[jcjeant]

Hi,

clandestino
Besides, it would add some credibility to the statement of yours if you could provide quote of Airbus chief pilot.This air chief pilot quote is in a video (in french) posted earlier in this thread
clandestino
Pilots were so unfazed that they didn't even make reports.Do you think this behavior normal ?
This is in contradiction with the rules
clandestino
Yes, if we apply selective and very narrow hindsight. Every aeroplane type has dozens if not hundreds technical issues being investigated simultaneously. How can you determine which is minor, which major and which will turn out to be lethal if left unchecked long enough? Before AF447 it seemed that UAS is somewhere in the middle of the seriousness scale as pilots have successfully coped with it. There was no rush to change the offending pitots.August 2001:
The DGAC mandates the replacement of the sensor Rosemount probes by the
Goodrich and Thales AA by AD 2001-354 (B) (Appendix 3).

July 2002:
In the OIT 999.0068/02/VHR SE (Annex 4), Airbus made ​​the observation of defects
probe Thales (formerly Sextant) P / N C16195AA.

December 2002:
The FAA mandates the replacement of the sensor Rosemount probes by the
Goodrich and Thales AA , specifying the hazard out of the flight and that is the answer to an "unsafe condition" (Annex 39)

January 2005 : Thales launch the project « ADELINE » (annexe 5). Actual air data equipment is composed of a large number of individual probes and pressure sensors. This equipment delivers vital parameters for the safety of the aircraft’s flight such as air speed, angle of attack and altitude. The loss of these data can cause aircraft crashes especially in case of probe icing.

[Lyman]

Pilots were so unfazed that they didn't even make reports.
....Clandestino

This is iPad Facto from the releases, and not a clear finding, certainly not expressed in this way.

If this statement is casually accurate, the fault is with the regulator, via the airline. The airline is responsible, in an agency, for the regulations. The Pilots, as representatives of the line, are the visible ones, but to understand "unfazed" the culture at AF is on the hook.


The decision maker acts according to his/her understanding of the situation, and the source of error is in the decision maker's knowledge base or in the process of reaching a decision. ....Orasanu et al

With respect, this is incomplete. It is a poor judge who lays off a decision on knowledge alone. Including "process" does not help.

One can have excellent knowledge base; without experience, it is not only partial, it is dangerous to believe data can fly. Untrained, U/A recovery is a crapshoot, and UAS recovery the same. Machinbird has demonstrated this fully, as others have, and does one doubt the lack of training will remain unaddressed in the report?

Has anyone here had a singular experience in the sim, without help, in UAS recovery, though conversant in the platform's operation? Dozy?

[Old Carthusian]

ALF
I see your point but can't find myself in agreement with it. We do not have any evidence that the crew actually followed any procedure to identify what the cause of the initial situation was. This would seem to go against their training. Hindsight bias would appertain if for example they chose an SOP other than UAS and we state well they should have followed UAS instead. However, to say that they should have followed a course of action to analyse the situation which fits in with what we might reasonably expect was trained does not show hindsight at all. One should have expectations that trained behaviour should be followed and in this situation we can't say that this was the case. Note I am not saying that they should have followed the UAS drill but that they should have followed an analysis procedure which allowed them to arrive at an appropriate conclusion about the situation they were in. This is what airline pilots are supposedly trained to do. I cannot see any hindsight bias in this.

[Lyman]

We do not have any evidence that the crew actually followed any procedure to identify what the cause of the initial situation was.

We also have not seen a procedure to follow.

[Machinbird]

ALF posted a link to a very appropriate paper. The gist of it is in 3 key paragraphss.

Thus, there are two major ways in which error may arise. People may (a) develop a wrong interpretation of the problem, which leads to a wrong decision because they are solving the wrong problem -- an SA error, or (b) establish an accurate picture of the situation, but choose the wrong course of action -- a CoA error.

Situation assessment errors can be of several types: situation cues may be misinterpreted, misdiagnosed, or ignored, resulting in a wrong picture; risk (threat or danger) levels may be misassessed; or the amount of available time may be
misjudged.

Errors in choosing a course of action may also be of several types. In rule-based decisions, the appropriate response may not be retrieved from memory and applied, either because it was not known or because some contextual factor mitigated against it. In choice decisions, options also may not be retrieved from memory, or only
one may be retrieved when in fact multiple options exist. Constraints or factors that
determine the adequacy of various options may not be retrieved or used in evaluating the options. Finally, the consequences of various options may not be considered. The decision maker may fail to mentally simulate the possible outcomes of each considered option. Creative decisions may be the most difficult because they
involve the least support from the environment. The absence of available options means candidate solutions must be invented to fit the goals and existing conditions.

I can see AF447 as Situation Assessment error leading to a Course of Action error (Creative). The initial roll oscillation figures into this.

[Machinbird]

Quote:
Originally Posted by Machinbird
Hey Clandestino, we are talking about trained pilots, not random guys you pick up on the street.

When I'm talking about Yuri Gagarin succumbing to spiral dive in cloud or Charles Basset and Elliot See perishing in controlled flight into building, I'm talking about astronauts, not some random airline pilots. Clandestino
Where did you get that about Yuri Gagarin? The Russians to this day do not really know what happened to his aircraft other than both guys rode it in.

As for Elliot See flying into the building--how many circling approaches do you think he had made in his life? (I'll bet very few.) His initial approach as a section of two aircraft was FUBAR and his wingy (Gene Cernan) lost sight during the subsequent circling approach and wisely pulled up into the clag for another go on his own. It seems as if visibility was worse than given to the crews and was not suitable. The whole circling thing was improvised on the spot from all appearances. Is it any wonder it didn't turn out well?

Quote:
Originally Posted by Machinbird
One thing that demonstrably took much of PF's attention during the first 35 seconds after the AP drop was the very significant roll oscillation and the method used by PF to control the oscillation.

Roll oscillation before stall was of low frequency, low and decreasing amplitude. It spells: insignificant and irrelevant. After stall all bets regarding roll control are off, unless you happen to fly some extremely aerobatic aeroplane, which A330 is not. Even if notion that preoccupation with roll precluded control in pitch were true, pilot unable to control the aeroplane around two axes simultaneously is severely incapacitated.
This looks like a Clandestino opinion piece. Do you have any facts to back it up? Have you tried it in a simulator? Have you mapped out and analyzed the roll oscillation?

Everything I've read about PIO events indicates that it is like the aircraft suddenly seems to switch from a Dr. Jekyll to a Mr. Hyde personality. What frequencies do you think PIO events tend to occur at? They are relatively low frequencies where the pilot is able to make inputs into the cycle. The only problem is that the inputs contribute to the oscillation.

[Sillypeoples]

Read the CVR breakdown.

The comments and such indicate lack of situational awareness not lack of hand flying skills. FO tried to correct, left seater took over, he comments that he can't figure it out, and by this time the captain, probably with his head in the middle comments he can't figure it out either.

Honestly I can't believe no one else is seeing this...but if there was a loss altitude from FL3700 to sea level...someone would be reading off a VSI and decreasing altitudes...nope...comments indicate that the only indication of an impending crash was the Ground prox (pull up pull up).

If I were to guess, and it's just that...lighting strike took out their avionics and fly by wire. AP disconnects as it's not getting reliable information...from where you say? The computer...pilots are now handflying bland tubes, maybe rebooting...they have not attitude indication, much less AS or alt...

Anyone here with Airbus experience flown the standby gyro with no AS or Alt?

[TTex600]

*
We do not have any evidence that the crew actually followed any procedure to identify what the cause of the initial situation was.

We also have not seen a procedure to follow.

Good point. The rote is trained, the thinking is not.

[PJ2]

Lyman, TTex600;

Quote:
Originally Posted by Lyman
*
Quote:
We do not have any evidence that the crew actually followed any procedure to identify what the cause of the initial situation was.
We also have not seen a procedure to follow.

Good point. The rote is trained, the thinking is not.

Well, we know what documents are available that deal with the UAS and ADR abnormals. We don't yet know what's trained. I referenced some documents in a post to Flyinheavy, on June 1: http://www.pprune.org/tech-log/482356-af-447-thread-no-8-a-53.html#post7222304 .

So we know at least, that the information to deal with the UAS event and/or failed ADRs was available and provided very specific guidance on how to do the memory items, the checklist items and what the thinking was behind the 2006 update. The thinking is clear, but again we don't know what the training actually was with reference to these documents. Also, these documents may not be available to all operators. They are not "required" for action in the same sense as, say, an AD.

O.C.

I thought about your response and agreed with it because to pilots it makes sense..."If not the UAS drill/checklist specifically, why not the standard SOPs at least?"

To be clinically accurate with reference to alf5071h's point concerning hindsight bias, we still have hints of the statement, "Why didn't they stick to SOPs?" One way to examine the question is, "How far back do we go before making up our minds as to what happened?" Can we ever make up our minds and say?


The other side of this same question is here, in PPRuNe: We have spent nine threads and three years and are still unable to say why, and we remain unable to say why the aircraft was pitched up and, more importantly, why it was held there when all of us who fly transports know that the airplane is going to run out of energy with the pitch attitudes recorded in the data. We know this to be true and expect that others who do this work would know too. How do we sort that out so that realistic, preventative action may take place? Or is hindsight bias increasingly serving the courts?

Acknowledging the phenomenon of hindsight bias still permits learning and change from "mistakes" but not because of the assumptions we may about such (assumed) "mistakes" or pilot behaviour which we can read in the tiny little bits of data we have from the recorders. How we learn is perhaps captured in the statement we're all familiar with: "The crew did not wake up that morning intending to have an accident." We might even extend this to organizational thinking.

From Dekker's, Drift Into Failure:

"The idea of the amoral calculator, of course, works only if we can prove that people knew, or could reasonably have known, that things were going to go wrong as a result of their decisions. Since the 1970's, we have 'proven' the time and again in accident inquiries (for which the public costs have risen sharply since the 1970's) and courts of law. Our conclusions are most often that bad or miscreant people made amoral trade-offs, that they didn't invest enough effort, or that they were negligent in their understanding of how their own system worked. Such findings not only instantiate, but keep reproducing the Newtonian-Cartesian logic that is so common-sense to us. We hardly see it anymore, it has become almost transparent. Our activities in the wake of failure are steeped in the language of this worldview: Accident inquiries are supposed to return probable 'causes.' The people who participate in them are expected by media and industry to explain themselves and their work in terms of broken parts (we have found what was wrong: here it is). Even so-called 'systemic' accident models serve as a vehicle to find broken parts, though higher upstream, away from the sharp end (deficient supervision, insufficient leadership). In courts, we argue that people could reasonably have foreseen harm, and that harm was indeed 'caused' by their action or omission. We couple assessments of the extent of negligence, or the depth of the moral depravity of people's decisions, to the size of the outcome. If the outcome was worse (more oil leakage, more dead bodies), then the actions that led up to it must have been really, really bad. The fine gets higher, the prison sentence longer.

t is not, of course, that applying this family of explanations leads to results that are simply false. That would be an unsustainable and useless position to take. If the worldview behind these explanations remains invisible to us, however, we will never be able to discover just how it influecnes our own rationalities. We will not be able to question it, nor our own assumptions. We might simply assume that this is the only to look at the world. And that is a severe restriction, a restriction that matters. Applying this worldview, after all, leads to particular results."

- Dekker, Sidney. Drift Into Failure, Surrey, Ashgate, 2011, p.5-6

[Organfreak]

PJ2 done wrote:
To be clinically accurate with reference to alf5071h's point concerning hindsight bias, we still have hints of the statement, "Why didn't they stick to SOPs?", when we have spent nine threads and three years unable to say why, and we remain unable to say why the aircraft was pitched up and, more importantly, why it was held there when all of us [emphasis mine] who fly transports know that the airplane is going to run out of energy with the pitch attitudes recorded in the data.

This puts me right back to the simplistic thinking (and sorry to snip the rest of your totally germane post), that there HAD to have been something wrong with the displays. It's the only answer that makes sense to me. Data has been withheld in the interim reports, as has been stated here many times.
Go ahead, shoot me down; I don't care; I can't fall very far from my armchair. :8

[PJ2]

Organfreak;

Regardingf what was on the PF's PFD/ND displays, it has been argued before, but inconclusively, like the argument that the PF was following the FDs. We just don't know and there is no data which tells us that this is what occurred.

What's more, once open, those kinds of doors swing both ways - as much as one may be totally convinced that one's notion is correct regarding what occurred and why, someone else may posit an entirely reasonable counterexample and there you are...mere theory, no fact, no conclusion or worse, dangerous conclusion(s).

We are not paralyzed; we are in a new "evidence space" which directs responses differently.

[Organfreak]

Well PJ2, I fully realize there are no facts or evidence to support-- I'm indulging myself in a completely groundless speculation, just for once, because mindless certainty feels so much better than the unknown. :)

[PJ2]

Yes, it does, until it doesn't! ;-)

The notion of "amoral calculation" was used by Vaughn in her book on Challenger. She slowly shifted in her view that NASA engineers and managers intentionally placed the shuttle and the crew at risk due to production pressures and long-term cost-controls. She eventually concluded that the very opposite was occurring...that everyone thought that they were doing exactly the right thing.

I think we can take it that the PF thought the same thing. I am hoping that the BEA HF Group can do for the crew of AF447 and all those affected, the same thing that Vaughn did for the crew of Challenger.

[Lyman]

The hard data is in the ACARS...The crew were not privy. Neither were they privy to data supplied for the post mortem via the recorders. Unwinding a little bit of the conclusionary tone here, Organfreak has repositioned the discussion.

Unless and until the complete record is available, even the BEA report will need a salt shaker.

PJ2:

"....say why the aircraft was pitched up and, more importantly, why it was held there when all of us who fly transports know that the airplane is going to run out of energy with the pitch attitudes recorded in the data."

Without knowing the state of the displays, the rhetoric has the crew in the corner, perhaps forever. It remains to be seen that the conditions were benign re: recovery. By benign I mean framed so by those who would condemn......

Re: Vaughn/Challenger. I never thought the Challenger case due malevolence. The incident happened post launch, thus inviting hindsight bias from the outset.

What I do think, is that Staff made a decision that involved risk management, out of their job description, and without proper oversight. Doubt can save the poodle, or kill it....In the Challenger case, the structural process was abdicated/co-opted, by those who ignored the safeguards. Negligent? Of course....

It is chilling to think that these situations can crop up just as they did when we did not know "better".....

[safetypee]

When considering the differences between events, some of the initial climbs were with autopilot engaged, AF447 was not.
Is there any difference in the pitch trim rate between autopilot engaged and manual flight, between normal and alternate law, or between any of the previous options and that which might be seen with over-speed protection?

[Organfreak]

Lyman,
Organfreak has repositioned the discussion.

Strictly by accident, I assure you. I doubt I have that power. Sorry if I was rude to you last week, even if you did deserve it. :O

[Organfreak]

Safetypee, great handle!
It is my understanding, as discussed in thread #s Gazillion, that this particular flavor of ALT Law included full auto-pitch trim. Apparently, to catch you up, it did exactly as PF commanded, which was to wind-up to almost full nose-up. Doubtful if this helped. It has been opined by somebody here that there's no good reason for auto-trim in ALT2B, and probably added to the confusion.

[safetypee]

Organfreak, thanks. My line of thought is if there were to be a difference in trim rates, then the manual-flight trim-follow-up could result in a more extreme attitude (or lower trimmed airspeed) than for autopilot/autotrim for the same duration; where duration might be the satisfaction of a flight guidance (FD) command.

An alternative view of this might be any difference in the flight control pitch rate limit between manual and autoflight (or over speed pull-up); expecting that manual flight would enable higher pitch rates than for the autopilot.

[AlphaZuluRomeo]

Hi

Answering here to A-FLOOR, from the thread "Humbling sim experience", in an effort not to hijack it for too long ;)

Re: Overspeed and understanding of stall situation in AF447
Have you read the CVR transcipt?
Yes I did, thank you. En français dans le texte, qui plus est. :)
1/ At one time, the PF though the aircraft was (too?) speedy ("J’ai l’impression qu’on a une vitesse de fou non qu’est-ce que vous en pensez ?") but the aircraft was not. As the overspeed protection listen to its sensor inputs, and not to the PF mind, I maintain: no overspeed detected, hence no activation of overspeed protection.
2/ I fail to see where the transcript shows the crew was aware of the stall. OTOH, there are parts which show they weren't ("comment ça se fait qu’on continue à descendre à fond là ?")

My point was that with elevators alone the aircraft will drop the nose again when the elevator backpressure is released, but this may no longer be the case when the THS is trimmed fully aft.
Releasing the back pressure on the stick may be not enough, as the FBW will then try to maintain path/g load. If the stick is placed and held nose down, the nose will drop. It takes more time as long as the THS full nose-up, but it works, and if maintained the THS will come back from its "full nose-up" position.
NB: I do however agree that it's not a good idea for the auto-trim to go full nose-up when the SW is on (point discussed at lengh in one of AF447's dedicated thread).

I know of no Boeing type which has an Airbus type autotrim system that automatically trims the THS to relieve pitch input. In manual flight, even the 777 and 787 have to be trimmed manually for airspeed using the trim switches. This does not take into account some functions where the trim is adjusted automatically with flap and speedbrake deployment (...)
OK, wasn't aware of that. Thx. :)

[NeoFit]

Have you read the CVR transcript?
Yes, of course.

Three years after the horrific event, and despite the fantastic PPRuNe members knowledge, F-GZCP wreckage remains incomprehensible.


IMO, here (http://www.globalsim.web.id/publicservice/AF447/AF447JulyReportVer13.pdf) is a very interesting link where you can see both CVR and FDR transcripts.

I have printed it (3 pages needed to see some data), and also IR#3 (En) pages 29-30-31 (and take a pencil to add some "zero lines" or other line ...)


Regards

[Clandestino]

This air chief pilot quote is in a video (in french) posted earlier in this threadThanks, now we found out it is Airbus chief test pilot, mr Rosay, could now someone please translate what he actually said, for the benefit of us not understanding French?

Do you think this behavior normal ?I'll refrain from definitive judgment, as I don't feel qualified enough to draw the line of normality. However, on normality scale, finding UAS so ordinary to not even report it is far, far more normal than trying to climb the aeroplane above its ceiling just because airspeed indication got messed up.

This is in contradiction with the rulesHow would anyone know what the rules were? The data is de-identified, you don't know whether there was safety management system with compulsory/confidential reporting scheme in the place at the time of the occurrences, let alone what airline did the alleged offenders fly for.

Rest of your post is completely irrelevant to AF447; it refers to earlier replacement of Rosemount probes with either Goodrich or Thales. Yup, Thales probes were found to be superior to Rosemount's.

This is iPad Facto from the releases, and not a clear finding, certainly not expressed in this way.This statement of yours is radically at odds with the truth, as what I mentioned is clearly stated on page 65 of interim2. Interim doesn't mean it is not official. Just not final. Yet.

If this statement is casually accurate, the fault is with the regulator, via the airline. The airline is responsible, in an agency, for the regulations. The Pilots, as representatives of the line, are the visible ones, but to understand "unfazed" the culture at AF is on the hook.
The airline is not identified in the report. Your notion it's AF might eventually turn out to be correct but for the time being it's pure conjecture.

We also have not seen a procedure to follow. Anyone suffering from this condition can be quickly and efficiently cured by gazing upon interim1, page 69 or interim3, page 59.

Where did you get that about Yuri Gagarin?In the article about spatial disorientation, published in internal air force magazine, some 23 years ago (if you wonder: my father was reserve captain in the army that started to crumble at the time so he could get away with sneaking away a few issues of GRViPVO to his aeroplane-crazy son). There was nice illustration, allegedly based on radar plot, of MiG-15 UTI entering the cloud, reversing its heading and completing two full spirals before hitting the ground. Point of the article, with which I fully concur, was that spatial disorientation can happen even to the best and most experienced pilots. That former fighter pilot can be offended by the suggestion is quite surprising to me. Frankly, I find it even a bit appalling.

The whole circling thing was improvised on the spot from all appearances. Is it any wonder it didn't turn out well?So how does it fit in with your "We are talking about trained airline pilots here" umbrage? He was astronaut, far better trained than any airline jockey, yet he died making what uninformed call "beginner's mistake".

This looks like a Clandestino opinion piece. Sure it is. It's my opinion based on DFDR readouts, precisely rendered on pages 29-31 of interim3. Where do you find fault in it?

Everything I've read about PIO events indicates that it is like the aircraft suddenly seems to switch from a Dr. Jekyll to a Mr. Hyde personalityAgain, I find such a notion coming form an carrier qualified ex-phantom driver a bit disturbing. Aeroplane doesn't change a bit, it is the unfortunate pilot that gets into phase with its oscillation.

Anyway, maximum roll before the aeroplane stalled was 11°, which can be called significant only by severe stretch of imagination. However, from DFDR data it is pretty clear that CM2 actively and successfully dampened the roll, therefore he was very aware of the aeroplane's bank so we can lay the theory "he did not see instruments" to rest.

Has anyone here had a singular experience in the sim, without help, in UAS recovery, though conversant in the platform's operation? Dozy? Please everyone: read the following paragraph carefully. Reread it if it's not clear after the first reading. Come back and ask questions if still unsure you understood it. Refer to interim2 for more information.

There were more than thirty cases of UAS similar to AF447 on A330 and A340 aeroplanes. Almost all of them included autopilot disconnect and reversion to alternate law. All of them ended without damage to aeroplane or injury to passengers. Airlines involved are not explicitly stated, yet from the date of the occurrence and MSN of the aeroplane it can be easily determined. There were some incidents involving the Air France.

Therefore:
Notion that unreliable airspeed must be fatal on Airbus is false.
Notion that most of the contemporary Airbus pilots are unable to handfly the beast in alternate law at cruise level is false.
Notion that every Air France pilot is so ill prepared for the UAS on 330/340 they are bound to crash if and when it occurs is false.

If I were to guess, and it's just that...lighting strike took out their avionics and fly by wireIf you were to guess only based on CVR, it would be pretty reasonable thing to assume but there is no need to do that as DFDR data is available. No electronic or mechanical failure was detected. Yes, you have read it correctly: no failure! Sensors kept on measuring the pressure which was no longer actual total, as pitot orifices were blocked by ice and that's what cascaded into AP loss and reversion to ALTN2. Per design and a good one, too.

we remain unable to say why the aircraft was pitched up and, more importantly, why it was held there when all of us who fly transports know that the airplane is going to run out of energy with the pitch attitudes recorded in the data.That's something both CM2 and CM1 forgot just before the accident. I'm speculating but perhaps they were too knackered to think straight?

The crew did not wake up that morning intending to have an accidentNot just that. We can be pretty certain that CM2 strongly believed he was saving himself and everyone on board from a threat that he unfortunately did not name for the sake of CVR. That his actions were just the opposite of needed is beyond tragic.

[mm43]

Originally posted by A-FLOOR ...
(in the "humbling sim experience" thread)


... the captain correctly remarked on his return to the FD that the aircraft was stalled.
Have you read the CVR transcript?

You must be privy to a CVR version somewhat different to that published by the BEA.:confused:

The Captain did say at 2 h 11 min 52, "Well look take take that".

So why persist that the crew knew the aircraft was stalled, when there is no supporting evidence.:ugh:

[OK465]

It has been opined by somebody here that there's no good reason for auto-trim in ALT2B, and probably added to the confusion.

Could anybody explain the specific difference(s) between ALT2"A" (I assume there is such a thing) and ALT2B?

Standing by...:)

[Lyman]

mm43

Not sure re: CVR, but it was reported, among other comments, that "I understand nothing", "We have crazy speed", AND (from Captain, on return) "What are you doing, this is a Stall".

The latter did not end up in the CVR releases, but a lot of other stuff may not have as well. "Er.. What are you doing" did make the report. For now, I reject the comment re; STALL, however, unless the entirety of the audio is released, we will not know, ever. Likewise, I am unclear as to why CONFiture's comment is unaddressed: "Vmode trace" not in the record.

[jcjeant]

Rest of your post is completely irrelevant to AF447; it refers to earlier replacement of Rosemount probes with either Goodrich or Thales. Yup, Thales probes were found to be superior to Rosemount's. Not at all .. this show how much earlier (far before the AF447 event) was the preoccupation about the Pitot tube problem and it's possible consequences ....
I want to remind you what you posted
clandestino
Before AF447 it seemed that UAS is somewhere in the middle of the seriousness scale as pilots have successfully coped with it. There was no rush to change the offending pitots.And what I posted ...
jcjeant
August 2001:
The DGAC mandates the replacement of the sensor Rosemount probes by the
Goodrich and Thales AA by AD 2001-354 (B) (Appendix 3).

July 2002:
In the OIT 999.0068/02/VHR SE (Annex 4), Airbus made ​​the observation of defects
probe Thales (formerly Sextant) P / N C16195AA.

December 2002:
The FAA mandates the replacement of the sensor Rosemount probes by the
Goodrich and Thales AA , specifying the hazard out of the flight and that is the answer to an "unsafe condition" (Annex 39)

January 2005 : Thales launch the project « ADELINE » (annexe 5). Actual air data equipment is composed of a large number of individual probes and pressure sensors. This equipment delivers vital parameters for the safety of the aircraft’s flight such as air speed, angle of attack and altitude. The loss of these data can cause aircraft crashes especially in case of probe icing. Yes .. indeed .. despite all the earlier preoccupations .. it was unluckely no rush ......
clandestino
Thanks, now we found out it is Airbus chief test pilot, mr Rosay, could now someone please translate what he actually said, for the benefit of us not understanding French?In the video .. the interviewer ask Mr Rosay .. what the AF447 pilots had to take as action when the event occured
His aswer was .... do nothing !
Clandestino
In the article about spatial disorientation, published in internal air force magazine, some 23 years ago (if you wonder: my father was reserve captain in the army that started to crumble at the time so he could get away with sneaking away a few issues of GRViPVO to his aeroplane-crazy son). There was nice illustration, allegedly based on radar plot, of MiG-15 UTI entering the cloud, reversing its heading and completing two full spirals before hitting the ground. Point of the article, with which I fully concur, was that spatial disorientation can happen even to the best and most experienced pilots. That former fighter pilot can be offended by the suggestion is quite surprising to me. Frankly, I find it even a bit appalling.

So how does it fit in with your "We are talking about trained airline pilots here" umbrage? He was astronaut, far better trained than any airline jockey, yet he died making what uninformed call "beginner's mistake".
Gagarin was not really an experienced pilot ... (check his flight hours ...)
And when he was incorporated in the space program .. he fly very little time .. (or not at all) just for keep up to date his pilot papers (license)

Reference
Starman by Jamie Doran and Piers Bizony
Although he was the most famous pilot in the world, he was not a particularly experienced one. Telltale clues can be discovered even to this day in the museum at Star City, where a number of Gagarin’s personal effects are preserved. His pilot’s log book is a much-venerated object, yet it makes disturbing reading. When he was recruited into the first cosmonaut squad at the end of 1959, his total flight time amounted to 252 hours and twenty-one minutes. Of this, only seventy-five hours had been spent as a solo MiG-15 pilot, first at Orenburg, then on station at Nikel in the Murmansk region. For a young Air Force lieutenant starting out on his career, this was not an especially poor total, although most of the other cosmonauts in his group had logged 1,500 hours or so. If he had stayed on active duty with the Air Force, Gagarin could have built up his flying time to become a superbly skilled fighter pilot. After he was recruited for training at Star City, however, he lost this opportunity altogether.

[Organfreak]

@OK465,

Heh heh, thought I had read of it here, so I parroted it. Looking at the FCOM, I see nothing of the sort. I sit, corrected. :\

[OK465]

OF:

No need for you to sit corrected. The IR refers to ALT2B.

And you are correct about the other documentation.

That's the point. :)

[Turbine D]

Lyman,

Your quote:
AND (from Captain, on return) "What are you doing, this is a Stall".

Where did "this is a stall" come from? I don't think I have seen this anywhere. IMO, what seemed obvious, the Captain never figured out what was happening upon return to the cockpit.

[Organfreak]

OK465,
WOW! That is damned interesting.

Here are the three pertinent pages of A330 FCOM, and sorry for the squashing of the images- (ah...the Mysteries of Photshop).

http://www.organfreak.com/images/A330controllaws1.jpg

http://www.organfreak.com/images/A330controllaws2.jpg

http://www.organfreak.com/images/A330controllaws3.jpg

[mm43]

@ LymanThe latter did not end up in the CVR releases, but a lot of other stuff may not have as well.The BEA have made it quite clear that comments made that were not relevant to the conduct of the flight were eliminated from the CVR transcript. If the stall warning had been acknowledged verbally in any form, or some speech construct inferring the like, then the BEA would be less than honest not to include it. I have no reason to suspect that either was the case.:=

[mm43]

@ OK465

It would seem that the major differences in ALT Laws are:-

ALT1:
Pitch attitude (Θ) protection lost.
Hi Speed and Stall speed are alternate.

ALT1A:
As ALT1 but Stall protection is lost.

ALT2:
As ALT1 but lateral normal law is lost and replaced by
lateral alternate (Roll = DIRECT; Yaw = Alternate)

ALT2A:
As ALT2 (Stall protection is lost)

ALT2B:
Pitch attitude (Θ) protection lost.
Hi Speed and Stall protection lost.
Bank angle protection lost

Source - A33Zab in AF447 Thread No.6 (http://%3Cb%3EAF447%20Thread%20No.6%3C/b%3E), and in

ALT2B no Hi and Lo speed stability (= VMO2/ Vc prot),

as explained earlier (http://www.pprune.org/tech-log/482356-af-447-thread-no-8-a-49.html#post7214889) in this thread.

[CONF iture]

Regardingf what was on the PF's PFD/ND displays, it has been argued before, but inconclusively, like the argument that the PF was following the FDs. We just don't know and there is no data which tells us that this is what occurred.
There is enough data to affirm FD were displayed at times. So there are more than obvious reasons to investigate what those FD were displaying for those periods. Everybody is questioning why the PF did what he did, the answer could be just there ...

[bubbers44]

Are there pilots that follow the flight director blindly? Didn't happen when I was flying.

[CONF iture]

Let me list some of the ways in which this statement is wrong
1. pulling can lead to high-mach-low-threshold transient stall warning if aeroplane is jerked into climb, reasonably smooth pull from about 1.5 to 5° will avoid it
Easy stuff in turbulence

2. when settled at 5° pitch, AoA will be near cruise pitch and will gently increase towards 5° as speed is bled off. By the time it gets there, you won't be at high mach anymore.
Easy stuff in turbulence

3. If no valid mach, stall warning reverts to low threshold
I like that ''If''

4. stall warning is not stall itself - a fact cheerfully ignored by those unable to tell the difference between "approach to stall recovery" and "stall recovery".
It does not matter, both should trigger the very same procedure (the new one) NOSE PITCH DOWN + THRUST REDUCE

5. when arguing about Habsheim showoff, you repeatedly claimed that alpha prot prevented aeroplane from achieving higher lift at even higher AoA (backside of the power curve, anyone?) and now all of a sudden, stall warning is considered to be the edge? Are you having it both ways or are you about to make a breakthrough in aerodynamics - discovery of the area of fantastic aerodynamic performance between alpha max and stall warning?
Because Alpha Max is simply not Alpha Stall Warning and Airbus did that for a reason.
Alpha Max = protection = do whatever you like = still flying
Alpha Stall Warning = Do NOT stay there = still flying but for how much longer ?

Airbus chief pilot has got all of it now : No more 5 degrees pitch up - Finished : "When you lose the speed indications in cruise, that is the most simple procedure to apply : You have to do NOTHING"

Clandestino, it could be understandable you recommend to apply 5 deg of pitch up as a first measure the time to get some figures from the QRH, but it is absolutely non sense you pretend to be comfortable to apply it vitam eternam. It tells a lot how you see yourself as a pilot ... as it shows in your writing style too.

[RetiredF4]

mm43


@ OK465

It would seem that the major differences in ALT Laws are:-

ALT1:
Pitch attitude (Θ) protection lost.
Hi Speed and Stall speed are alternate.

ALT1A:
As ALT1 but Stall protection is lost.

ALT2:
As ALT1 but lateral normal law is lost and replaced by
lateral alternate (Roll = DIRECT; Yaw = Alternate)

ALT2A:
As ALT2 (Stall protection is lost)

ALT2B:
Pitch attitude (Θ) protection lost.
Hi Speed and Stall protection lost.
Bank angle protection lost

Source - A33Zab in AF447 Thread No.6, and in

ALT2B no Hi and Lo speed stability (= VMO2/ Vc prot),

as explained earlier in this thread.

Thanks for reposting this list.

When BEA and others like Clandestino state, that other UAS events had a positive outcome, can the difference to AF447 partially be found in this list? BEA does not state in which kind of Alternate Law the other events ended, i couldn´t find it at least. So all those events could be just in simple ALT 1, quite a difference to the ALT2B AF447 dropped to.

[AlphaZuluRomeo]

Hi Lyman

Re: your #1215

I don't remember releasing "the entirety of the audio" is a standart practice (source: other accidents). More the contrary, in fact. In that light, presenting this release as "waited" as you do will only lead to disapointment/rise in conspiration theories when this release does not occur.
I'm aware of -at present time- two versions of the transcript:
- the official version (by the BEA, in IR3)
- the version "leaked" by Mr Otelli in his book, build from an earlier transcript of the CVR than that used by the BEA in IR3, as far as I can tell.
Even if both versions have been quoted numerous on times by various media, I'm not aware of any version/sub-version that contains the apparent recognition of the stall by any of the crew member. Would you be so kind as to provide a link to that version/sub-version/comment, in order for its credibility to be assessed?

Thanks :)

[HazelNuts39]

Alpha Stall Warning = Do NOT stay there = still flying but for how much longer ?Right! So where have we got to:

Either do nothing or -
- 5° pitch up will not stall the airplane
- pull up gently to avoid stall warning
- if stall warning occurs: reduce pull up
- use small, brief stick inputs, watch the result before making further inputs
- get the QRH for correct pitch and thrust setting

[thermalsniffer]

AZR:

Doomed Flight AF 447: An Airbus Programming Error? - SPIEGEL ONLINE (http://www.spiegel.de/international/world/doomed-flight-af-447-questions-raised-about-airbus-automated-control-system-a-765764-2.html)


"Exactly what orders he issued are not part of last Friday's report. But sources close to the investigation are saying that he said: "This is a stall. Reduce power and nose down!""

No comment on credibility of article, reporter, source, etc.

[OK465]

MM43:

Thanks for re-posting the list.

I respect A33Zab's obvious knowledge, but that list leaves a lot to be desired and has some flaws of logic and terminology in it if you were to use it for training, i.e.

ALT1A:
As ALT1 but Stall protection is lost.

ALT2A:
As ALT2 (Stall protection is lost)

...as if stall 'protection' (wrong term) is available in ALT2, but not lost until reconfig to ALT2A?? In any case both stall 'protection' & theta protection take a hike in all laws other than normal, so 1A, 2A are what exactly?? Just vanilla 1 & 2??

My question regards the difference in failure modes that would create one or the other level of reconfig. I would have thought that 2A & 2B are a function of how many ADR's get flaky, i.e.

1 flaky ADR = continued Normal Law
2 flaky ADR = ALT2A
3 flaky ADR = ALT2B

I guess I'd like to know how do I then get into each of these conditions and then how do I recognize which one I have, which ones 'latch', which can be recovered to a different level of reconfig, or do I even need to know any of this?

Simulators generally only provide a limited range of constrained failures to achieve one or the other reconfiguration level for training, so does the available documentation need to be enhanced?

A33Zab is an excellent source of info, but there's probably a lot of A330 pilots who don't even know he exists. :)

[OK465]

Are there pilots that follow the flight director blindly? Didn't happen when I was flying.

B44:

I trained a whole lot of pilots in the 727, and yes there were some who could get caught by this, even back in 'your day'.

[Lonewolf_50]

COnf:

4. stall warning is not stall itself - a fact cheerfully ignored by those unable to tell the difference between "approach to stall recovery" and "stall recovery".

It does not matter, both should trigger the very same procedure (the new one) NOSE PITCH DOWN + THRUST REDUCE

Conf, I will presume that your point is for stall at high altitude, or for an aircraft with underslung engines, since
At high alt/high mach, overspeed can be a risk
Reducing power on underslung engines removes some of the "pitch up" input from thrust vector being below, as opposed to coincident with, the longitudinal axis.

As I ponder the point you make, it seems a simpler response to lower the nose, as doing so you will decrease AoA without touching power.
However, if you reduce power => you reduce thrust => decrease airspeed / Mach ... so ... might your power reduction risk ofsetting a nose reduction and thus keep you near stall AoA if you are trying to avoid stall?

IS part of the nose down/power reduce response intended to cause an altitude reduction and thus change the performance environment of the aircraft?

In chewing over your point, I conclude that your recommendation is confined to approach to stall/stall in the high altitude / high mach environment.

Do I understand you correctly?

[AlphaZuluRomeo]

thermalsniffer

Thanks for the link. :ok:
I forgot about that... errr... is that a novel? ;)

No comment on credibility of article, reporter, source, etc.
Well, a simple thing:

"At no point" on the cockpit voice recorder "is the word stall ever mentioned," Chief Investigator Alain Bouillard said in an interview (http://www.avweb.com/avwebflash/news/air_france_447_investigators_stall_crash_204730-1.html).

So, as far as I'm concerned, source is dismissed. Thanks again. :)

[A-FLOOR]

mm43

Not sure re: CVR, but it was reported, among other comments, that "I understand nothing", "We have crazy speed", AND (from Captain, on return) "What are you doing, this is a Stall".
I'm somewhat surprised at the comments that the crew never mentioned being in a stall at all, as this is exactly how I remember it from reading an early report about the CVR transcript (capt telling his crew they are in a stall shortly after he returned to the FD). This is exactly one of the things which really stuck with me from reading that, so I'm dumbfounded how it ended up not being mentioned at all in the interim report.

Surely there must be other people who remember reading it as well?

[GarageYears]

Surely there must be other people who remember reading it as well?

Nope :=

In fact that "stall" was never mentioned was what stuck in my mind.

[Organfreak]

@A-FLOOR:

Well....no, sorry. That's the very first time I've heard that one, after following these threads closely since 6/09. This Der Spiegel article is full of other mistakes, misrepresentations, and inaccuracies as well. Forget it.

We've spent three years here trying to figure out how they didn't know they were stalled. (Not to mention why they pulled up, so I won't mention it.)

[roulishollandais]

Has anybody some information about
1. A330 feedback equations including speed parameter V ? and information about A330 cross-over velocity Vco?
C* =? Knz.nz + Kq.q and is it standard C* ?
2. relative position of the accelerometer ? in normal flight and stalling deeply,
3. where does the "speed" input in the feedback come from in the UAS case?

Thank you :ooh:

[CONF iture]

Right! So where have we got to:

Either do nothing or -
- 5° pitch up will not stall the airplane
- pull up gently to avoid stall warning
- if stall warning occurs: reduce pull up
- use small, brief stick inputs, watch the result before making further inputs
- get the QRH for correct pitch and thrust setting
The answer was in the revised procedure that never showed up, following the known and discussed cases of Air Caraibe. Airbus acknowledged it was necessary to think about something to help a crew in such circumstances … We are still in the wait … Is it part of the recommendation chapter in the coming report … ?

Airbus initially wrote the reply to UAS in cruise is to adopt 5 deg of pitch up. The BEA confirmed such procedure in their press conference. Now, Airbus, through his chief pilot, says differently …

Big clarification up is necessary regarding UAS procedures, more specifically at high altitude. Pilots need clear procedures and relevant TRAINING !

How to identify UAS situations (involving system malfunction): what are the key features, were these explained in training and associated with the range of recovery procedures. These are training issues, but also aspects of memory and recall in context.
The last time I did practice the exercise, it was just after take off and the first warning we got was : WINDSHEAR WINDSHEAR ... consistant with my airspeed going in the red.

[roulishollandais]

The decision of the Court of Cassation of France, that was expected June 15, finally arrives September 24, 2012.
It responds to the request of the Lawyer Me Soulez-Lariviere about the jurisdiction of the French criminal courts for a disaster in the non-territorial waters.
This was the case TOTAL, but also concern the flight AF447, since Mr. Soulez is one of the lawyers defending the leaders of major French civil aviation and has already expressed his opinion hostile to that jurisdiction to the crash of Mont Ste-Odile.

[CONF iture]

In chewing over your point, I conclude that your recommendation is confined to approach to stall/stall in the high altitude / high mach environment.

Not only.
Airbus has 2 published procedures now. Both are memory items.

STALL RECOVERY
STALL WARNING AT LIFT-OFF


So the first one must be applied at any altitude, except lift-off :
NOSE DOWN PITCH CONTROL … APPLY
In case of lack of pitch down authority, reducing thrust may be necessary.

Historically, the answer to a stall warning was to apply full thrust and reducing the AoA, minimum altitude loss was a factor. Now not anymore: Above all it is making sure to reduce the AoA first and reducing thrust may be necessary. Smoothly increasing thrust comes only after stall indications are no longer present.

[PJ2]

CONF iture;
The answer was in the revised procedure that never showed up, following the known and discussed cases of Air Caraibe. Airbus acknowledged it was necessary to think about something to help a crew in such circumstances … We are still in the wait … Is it part of the recommendation chapter in the coming report … ?

The "answer" showed up in 2006, in an Airbus presentation entitled, "Unreliable Speed; Latest Improvements (http://www.iag-inc.com/premium/AirbusUnreliableSpeeds.pdf)". References to the correct procedure for UAS were in a number of FCTMs by 2007, all before the Air Caraibes event.
Airbus initially wrote the reply to UAS in cruise is to adopt 5 deg of pitch up. The BEA confirmed such procedure in their press conference. Now, Airbus, through his chief pilot, says differently …
Yes, that's correct, they wrote that in November, 2002 under the heading, "Immediate Pitch Attitude and Thrust Guidance" followed by an admonition to "Respect the Stall Warning" and, "When the Flight Path is Stabilized" -Attitude/Thrust - Adjust".

This drill/checklist has gone through several revisions since its first appearance - the earliest I have is November, 2002.

The qualification to level off and troubleshoot when above circuit altitude or MSA clarifies the original checklist item, "When the Flight Path is Stabilized". Every drill, and guidance in the A330 FCTM emphasizes that leveling off and stabilizing the aircraft should be done as quickly as possible to avoid an overspeed. Stalling is not mentioned as a risk but every drill/checklist since 2002 also emphasizes the need to respect the stall warning. Later checklists provide guidance on the "flying technique to stabilize flight" with regard to pitch and power.

[jcjeant]

PJ2
Of interest, do you have a reference regarding the Airbus Chief Pilot's remarks on the change to the 5deg requirement? Thanks.CONF iture had already posted:
Airbus chief pilot has got all of it now : No more 5 degrees pitch up - Finished : "When you lose the speed indications in cruise, that is the most simple procedure to apply : You have to do NOTHING"This reference come from a video (docu about AF447 in french language) posted earlier in another thread ....
EDIT:
Thank you HazelNuts39 .. I was searching for the video :ok:

[HazelNuts39]

PJ2;
The video is (goto 21:40) here

[PJ2]

Ah yes, I do recall now, thank you all.

Link to two Airbus stall recovery documents - posted before, but to refresh:

http://fucampagne2008.unblog.fr/files/2011/08/updatedstallprocedure.pdf

http://orleans.neting.com.es/esa/ESA_Jazz/Airbus%20Stall%20and%20recovery.ppt

[Mr Optimistic]

There was a statement long ago from an official source who had heard the cvr that one striking feature was that the word stall was not uttered once. No reason to think otherwise now especially as to think otherwise would require an answer as to why the appropriate commands were not forthcoming.

[Lonewolf_50]

Confiture: thank you!
The clarification
"In case of lack of pitch down authority, reducing thrust may be necessary"

makes sense, and clears up my misunderstanding. :ok:

[Clandestino]

this show how much earlier (far before the AF447 event) was the preoccupation about the Pitot tube problem and it's possible consequences ....
(...)
Yes .. indeed .. despite all the earlier preoccupations .. it was unluckely no rush .... It was basically the same procedure for both Rosemount and Thales replacement: no emergency AD, no immediate grounding until the mater is resolved, just the timeframe in which all probes are to be replaced while aeroplanes could keep on flying. What is the point you are trying to argue?

Gagarin was not really an experienced pilot ..Are you trying to make a principle out of illustration? Namely: inexperienced=unsafe? So, what do you think was the experience in manual flight, at cruise altitude, in ALTN law of thirtysomething 330/340 crews that all of a sudden had to perform the feat? How come they survived?

His aswer was .... do nothing !Doing nothing would have saved them. So would executing the memory items. There are many combinations of power and attitude that will keep you flying. 17.9° pitch above MAX REC alt will not, even with TOGA.

How can one conclude that the exasperated (and a bit cut-off in post-production ) answer of mr Rosay to mediapersons working on dramatization of AF447 represents the one and only right thing to do, rendering all the prescribed procedures wrong, escapes me.

Easy stuff in turbulence Note on page 43 and graph on the page 42 of interim 3 clearly show that turbulence was of short duration, light to moderate intensity and has completely stopped by the time the second, fatal, pull was initiated. Notwithstanding whether "Easy stuff in turbulence" argument is true or not, it is utterly inapplicable in AF447 case.

I like that ''If''Your like or dislike does not alter the fact a bit. Page 20 of interim 3 refers.

It does not matter, both should trigger the very same procedure (the new one) NOSE PITCH DOWN + THRUST REDUCEIt's attempt at dumbing down the procedure to unachieavable level, no matter if it proposed by Airbus or some PPRuNer. Applying such a procedure for low level approach to stall can easily result in unnecessary deaths and damage to property.

but it is absolutely non sense you pretend to be comfortable to apply it vitam eternam.Straw man argument. It is supposed to be applied until QRH is brought out and correct values for weight found and set. If it takes five minutes of fumbling, it won't kill you in this five minutes. Or until the fuel runs out but that doesn't mean it should be applied indefinitely.

When BEA and others like Clandestino state,
It's not me and BEA, it's just BEA. I only repeated its findings for the benefit of those too lazy to look it up themselves or are too preoccupied with their pet theories/agendas to notice them.

that other UAS events had a positive outcome, can the difference to AF447 partially be found in this list?Maybe. What is the difference if low speed stability is available or not? It can be overridden by a pull on the stick and that certainly wasn't lacking.

Anyway, here's the important difference

Nine cases of triggering of the stall warning were observed.

(...)

The variations in altitude stayed within a range of more or less one thousand
feet. Five cases of a voluntary descent were observed, of which one was of
3,500 feet. These descents followed a stall warning;

(...)

The stall warning triggers when the angle of attack passes a variable threshold
value. All of these warnings are explicable by the fact that the airplane is in
alternate law at cruise mach and in turbulent zones. Only one case of triggering
was caused by clear inputs on the controls.


I guess I'd like to know how do I then get into each of these conditions and then how do I recognize which one I have, which ones 'latch', which can be recovered to a different level of reconfig, or do I even need to know any of this?Good question. Most important is to recognize that all the technical jargon about laws signifies that the safety nets are no longer there. Pilot able to understand the state of the aeroplane and to control it will perform well no matter the law. Pilot that gets disoriented and/or confused will not be saved by the computers in degraded FC laws.

[HazelNuts39]

The answer was in the revised procedure that never showed up, following the known and discussed cases of Air Caraibe. Airbus acknowledged it was necessary to think about something to help a crew in such circumstances …I'm afraid I can't follow your argument here. The issue whether or not the memory items apply was not addressed in the Air Caraibe Memo. Airbus said they would think about a modification of the checklists to address ACA's problem which was that their pilots were 'intimately' convinced that the two stall warnings were 'inapproprié', and had decided to disregard the phrase "RESPECT STALL WARNING AND DISREGARD 'RISK OF UNDUE STALL WARNING' STATUS MESSAGE IF DISPLAYED ON ECAM":
Phase8. Réunion « AIRBUS » :
o A l'initiative de notre Direction, une réunion s'est tenue au mois d'octobre dans les locaux de la société Airbus à Toulouse. A cette occasion, les ingénieurs nous ont présenté un bilan technique des deux incidents.
o Puis, à l'initiative de notre Responsable Formation, nous avons souligné toute la difficulté rencontrée par l'équipage pour la mise en application de la check-list « UNRELIABLE SPEED INDICATION » :
D En effet, dans sa partie développée en 3.02.34 page 17, celle-ci stipule «RELY ON THE STALL WARNING THAT COULD BE TRIGGERED IN ALTERNATE OR DIRECT LAW. IT IS NOT AFFECTED BY UNRELIABLE SPEEDS, BECAUSE IT IS BASED ON ANGLE OF ATTACK ».
D De plus, le paragraphe « TECHNICAL RECOMMENDATIONS » en page 2.22 du QRH mentionne « RESPECT STALL WARNING AND DISREGARD "RISK OF UNDUE STALL WARNING" STATUS MESSAGE IF DISPLAYED ON ECAM ».
D Or, l'accumulation de glace sur les différentes sondes s'est traduite par l'apparition de la procédure « ECAM » « F/CTL ADR DiSAGREE » qui implique le passage en « ALTERNATE LAW (PROT LOST) » cité ci-dessus. Elle comporte également dans sa page « STATUS » les mentions « RISK OF UNDUE STALL WARNING» et «UNDUE STALL WARNINGS MAY MAINLY OCCUR IN CASE OF AN AOA DISCREPANCY ».


° Malgré ces aspects contradictoires, les « PN T » du « FDF » ont su réagir face aux deux alarmes « STALL » inappropriées. De plus, les ingénieurs Airbus ont bien compris toute ia difficulté rencontrée par l'équipage pour une mise en application rapide et efficace de la procédure « UNRELIABLE SPEED INDICATION ». Ils ont convenu de la recevabilité de nos remarques et réfléchissent donc à une modification des check-lists. A suivre...
Voilà qui termine cette étude sur le givrage de nos Airbus A330-200. J'espère quelle aura répondu à vos questions.
Bons vols à toutes et à tous...

[jcjeant]

clandestino
Are you trying to make a principle out of illustration? Namely: I just wanted to point out that to illustrate your experienced pilots was about you had cited a bad example (Yuri Gagarin)
Yuri Gagarin was not an experienced pilot .. he was a celeb pilot .. not because his flying experience
Here is the gist of my comment .. no more no less