AF 447 Thread No. 10

[roulishollandais]

While that applies to the CVR, I was asking va about FDR and raw data interpretation. http://images.ibsrv.net/ibsrv/res/src:www.pprune.org/get/images/smilies/wink2.gif
The investigation report is both an analysis that requires the raw document, and a synthesis that accommodates many presentations more sophisticated.
The purpose of this investigation is to be extremely clear to pull all the fruits of the unhappy experience.
Thus ICAO has chosen to make public the CVR.Il also makes public radio conversations, although we have all sworn not to report the radio conversations. Isn't?
Drift occurred with time on the use of these reports. Trade secret has interfered in international civil aviation, while patents should always be published for the payment of royalties.

[AlphaZuluRomeo]

Well said :ok:
Indeed. Thank you Chris. :D

For one more rotation of the wheel: The CVR would be understandable only by those knowing enough french and english to do so.
"I do not trust anyone to interpret evidence for me." is a good point of view IMO, but for that one should:
- have to interpret evidence, i.e. not being a PPRuNer but a judge or someone involved, and
- possess the needed knowledge (of languages for the CVR, of technicalities for the FDR) and of course a serious background of the jobs.

Not meeting those criteria, I'm happy with the level of public release, pending the trial.

[Lyman]

I am on record as not wishing to hear the CVR, neither do I have the competence to interpret Raw Data.

If in fact the CVR contains a record of the Commandant du Bord as saying he was too tired to fly, and the Agency is guilty of not disclosing that, then however eloquent some may be in diverting attention from the issue to some anonymous poster(s) has not only no importance, but is impacting the safety of the industry negatively.

The status quo is not working.

We will see.

[DozyWannabe]

@Chris Scott - emphatic +1! :ok:

@Lyman:

Given the notorious flakiness of Italian media (and the Daily Mail's penchant for reprinting every bit of scuttlebutt it can find), I'm convinced the veracity of the claim is at best very dubious. Also, the Captain was not on the flight deck during the onset and initial response phases of the accident sequence - his return coincided with the point where recovery would have already been difficult, so logically it has no bearing on the most important timeframe.

Additionally, we know that while the PNF was on the same turnaround time as the Captain, the PF (who was effectively in command at the onset) had been on vacation for some time prior to the flight and was in effect on Rio de Janeiro time (IIRC his body clock would have been on roughly around midnight).

[jcjeant]

Fatigue Zzzzzz continued:

In the report of the judicial experts (available in french only)
My bold
pour toi », « Pour l'instant j'ai pas envie » lui répond il. Le CdB lui demande alors : « Où ils se font
les contact par HF d'après toi, à JIVTOL, ça devrait arriver, ça serait pas mal, ou FEMUR, on va
les contacter à FEMUR en HF », l'OPL précise: « Ah non, la FIR, c'est INTOL » ( la FIR est la
limite de la zone et c'est effectivement le point de contact par HF).
A 01h03.54 Un PNC féminin appelle de pilotage pour rapporter qu'il fait froid à l'arrière de la
cabine.
A 01 h04.19 Une personne pénètre dans le poste pilotage (sans doute GP accompagnant un membre
de l'équipage), à une question sur le sommeil, le CdB répond: « Cette nuit, j'ai pas assez dormi,
une heure, c'était pas assez tout à l'heure ».
La réponse du Dispatch précise que l'aérodrome a un accès restreint aux aéronefs en « emergency »,
il peut donc être retenu puisqu'en cas de déroutement, l'avion pourra être considéré en emergency. 01h04.19
Someone come in the cockpit (probably one person accompanying a crew member)
to a question on sleep, the Captain replied: "That night I did not sleep enough,
an hour, it was not quite enough time. "

[DozyWannabe]

"That night" - what night is he referring to?

And who are the "judical experts"?

[AlphaZuluRomeo]

jcjeant, that's a misleading translation.
« Cette nuit, j'ai pas assez dormi, une heure, c'était pas assez tout à l'heure »
« I didn't sleep enough last night, one hour was not enough earlier »
The second part ("one hour") refers to a nap IMO.

[Mr Optimistic]

Can somebody bring me up to date: what are we arguing about now ?

[AlphaZuluRomeo]

Dozy, the CVs of the experts are included in the judicial report.

Extracts...

1]
FAF engineer (FAS - Mirage IV)
Airlec engineer (single & twin engines aircrafts, helicopters)
DGAC, retired 2003
Private pilot (and ultra light)

2]
French Navy pilot
777 Captain (AF), FI
Retired

3]
A330 Captain (CORSAIR)
ITRE DGAC, TRI A320/A330

4]
5 years Airbus
Bureau Veritas (in relation with aeronautics)
Quality Director then Technical director (AIR LIBERTE)
Consultant since 2001

5]
A330 Captain (CORSAIR)
TRI/TRE
Manager (AIRLINAIR)

[jcjeant]

And who are the "judical experts"?
They are not masked .. like the "Anonymous" ...
• Charles MAGNE, Expert près la Cour d'Appel de Bordeaux
• Alain de VALENCE, Expert près la Cour d'Appel de Lyon
• Eric BRODBECK, Expert ayant prêté serment
• Michel BEYRIS, Expert ayant prêté serment
• Hubert ARNOULD, Expert près la Cour d'Appel de Reims

[AlphaZuluRomeo]

So much for not naming names when it's no use (my opinion).
Although the first one is really... no kidding? What did parents think?

[jcjeant]

So much for not naming names when it's no use (my opinion).Those names are from people know from the public and are in no way members of a secret society .. or protected by a non disclosure law and they will appear on the trial unmasked !

[OK465]

What did parents think?

:)

Bill (Learjet) Lear's daughter was named Chanda.

[atakacs]

It would seem for "leaks" that the whole crew did party the night before the flight. In any case I'm surprised that their whereabouts & activities could not be retraced. Maybe irrelevant, maybe not...

[AlphaZuluRomeo]

jcjeant,
You're free to name names, I'm free to tell I find this neither relevant nor elegant.
I'm by no means member of a secret society, but I don't like either being named on the web, where I know it will be archived in one way or another, without my consent or even knowledge.
This personal feeling makes me cautious for me, but for other people too, when not needed otherwise. I don't think names add anything relevant here. OTOH, qualifications do.

(sorry, personal mantra; will leave this OT now)

[DozyWannabe]

Having translated the "Mission" statement of that report (which can be found here) :

http://aerofuites.com/exp-jud-juin-2012/D06715-D06716-178-rapport-definitif-expertise-technique-du-2.pdf

It becomes clear that they were working at least in part *with* the BEA and reviewing the conclusions, not in isolation - so the idea that the BEA may be withholding anything doesn't stand up to scrutiny.

I'll try to translate the whole thing, but it'll take some time.

[roulishollandais]

@DozyWannabe
Thank you very much for the link and for your contribution! :):):)

[CONF iture]

http://www.pprune.org/7745206-post999.htmlFull CVR audio does not belong to the public but it belongs to the front crew.

Full CVR audio + full FDR data have to go to the pilot at the same time they go to the investigative body + manufacturer.

If I die on my job, I want my wife to have my data.
Too painful it will be for her to listen to the tape, but I have Friends I trust she can provide the information to, making sure every one is keeping honest in his duty.

[jcjeant]

It becomes clear that they were working at least in part *with* the BEA and reviewing the conclusions, not in isolation - so the idea that the BEA may be withholding anything doesn't stand up to scrutiny.Can be but be aware that those experts were appointed by the judge in charge of the case and therefore have the power of the law to access to all the documents they deem necessary
As you begin the hard work of translation .. you will realize that a lot of elements of this report do not appear in the final report of the BEA .. but were in the hand of the BEA
The experts (independent .. just like the BEA) deem to put those in their report for some reason
Note:
http://aerofuites.com/exp-jud-juin-2012/D06715-D06716-178-rapport-definitif-expertise-technique-du-2.pdf
It's only the first part of the report .. this is two more parts ( the second part of the report and one annexe ) for have the full report
Lot of stuff indeed ..

[Lyman]

IMO

The genesis of any opinion begins at the instant of first exposure to the evidence. Nothing in human experience is NOT opinion. Do we rely on numbers to form the best guess at Truth? (Consensus)? Works in politics. Less so in Darts, and should have no place in considered judgment.

Do we assign agents to make determinations? Of course. Rather than one agency composed of ten agents, perhaps three agencies, composed of three agents each.

REVIEW, then.....We wll see.

[HazelNuts39]

two more parts for the whole reportWhere are they?

[AlphaZuluRomeo]

jcjeant, you may not like it, but the BEA mission is not to disclose everything they got their hands on.
The mission is to analyse the facts and provide a report including recommendations as to how avoid a repetition of the facts (and the final accident).

Now, about the judicial report (not read entirely), it contains a synthesis of the flight (§6.3). I quote it below: Dozy, it might be easier to translate without copy/paste errors from the PDF.
The report also contains a more detailled description & analysis in its §6.2.x but that is too long to be quoted here.

Du décollage au FL350

La route suivie est conforme au plan de vol et se déroule conformément aux prévisions.
Un défaut de toilettes, sans conséquence, est transmis automatiquement au centre de maintenance d'Air France.
Le vol est sans turbulences notoires.


En croisière jusqu'au point INTOL

A cette heure de la nuit, alors que la charge de travail est faible et que la fatigue se fait sentir, l'équipage remplit les obligations de la préparation de la traversée de la zone ETOPS sans dynamisme.


En croisière du point INTOL à l'arrivée de l'OPL de renfort

Malgré les interrogations formulées par l'OPL PF, le CdB ne s'implique pas dans la conduite du vol et n'apporte pas de réponse sur la conduite à Venir face à la masse nuageuse identifiée sur la route.


De l'arrivée de l'OPL de renfort à la première alarme

Le CdB est passif lors de la relève et laisse le PF faire le briefing.
Le PF conscient de l'importance de la masse nuageuse informe le PNC.
Le PNF analyse la situation et prend l'initiative du choix de l'évitement latéral.


De la première alarme au décrochage

02h08'00" à 02h11'04"
Les actions de l'équipage sont en lien avec l'environnement constaté et aux informations disponibles mais ne répondent pas à une procédure en vigueur sur ce type d'avion.

02h10'04" à 02h10'14"
L'équipage réagit sans stress apparent à la première alarme en restituant une procédure connue et assimilée : contrôle de la trajectoire et actions immédiates.
L'accumulation des messages, associée à des alarmes sonores successives perturbe la perception de la situation.
L'OPL PF poursuit les actions initiées dans la séquence précédente pour la protection des moteurs, mais l'OPL PNF ne participe pas.
L'alarme STALL est perçue avec surprise sans diagnostic ni actions liées.

02h10'14" à 02h10'26"
L'équipage fait le constat, sans analyse, de la perte des indications de vitesse.
L'effet de surprise lié à l'alarme STALL qui retentit une deuxième fois est fort.
Face à l'incompréhension de la situation, le PNF cherche dans la lecture partielle et désordonnée de l'ECAM une justification à ce qu'il perçoit, et revient à son projet d'action initial de prévention des conditions givrantes.
Les perceptions de l'équipage ne sont pas suivies d'un diagnostic. En conséquence aucun traitement de panne n'est initié.
Le PF est concentré sur le maintien de l'inclinaison en raison de la loi directe en roulis et n'assure plus la maitrise de la trajectoire dans le plan vertical.

02h10'26" à 02h10'32"
L'alarme C-Chord initie un processus Perception-Diagnostic-Décision-Action partagé par l'équipage et cohérent pour l'écart d'altitude supérieur à 300ft.
Le vocabulaire inadéquat révèle une augmentation du niveau de stress.
Le mode de réversion V/S conduit à avoir des des barres de tendance centrées.

02h10'32" à 02h10'49"
Le PNF guide le PF pour la maîtrise de la trajectoire verticale en s'appuyant sur un diagnostic validé, mais change de projet d'action sans s'assurer de la mise en descente réelle de l'avion.
La commutation des sources ADR et IR est la recherche d'une information valide et non le résultat d'une analyse ou l'application d'une procédure.
Les barres de tendances sont centrées pour une assiette de 6° et une vitesse verticale de 1400 ft/mn en montée.

02h10'49" à 02h11'12"
L'équipage composé de deux OPL n'a pas fonctionné suivant la répartition des tâches définie pour un équipage composé d'un CdB et d'un OPL.
Le PNF s'est focalisé sur le retour du CdB pour retrouver une hiérarchie habituelle d'autorité.
La procédure STALL WARNING n'a pas été appelée.
Le suivi de la barre de tendance profondeur du Directeur de Vol a contribué au maintien d'une assiette à cabrer forte.


Du décrochage au retour du Commandant de Bord

02h11'12" à 02h11'42"
L'équipage perçoit la situation anormale niais ne peut élaborer un diagnostic en raison d'éléments contradictoires : Alarme STALL, pleine poussée, assiette affichée en accord avec les barres de tendance.
Le pilotage avec les seules références basiques du VSV* n'est pas assuré par le PF.
Les indications du Directeur de Vol sont toujours à cabrer.
La perte de contrôle est réelle, perçue par le PF comme une vitesse élevée et par le PNF comme la perte des commandes de vol du coté PNF.
L'avion est hors du domaine de vol connu. Dès lors la possibilité de sortie du décrochage ne peut être établie.

* VSV : vol sans visibilité, terme utilisé pour le pilotage à l'aide des seuls instruments (sans références extérieures)


Du retour du Commandant de Bord à la fin des enregistrements

02h11'42" à 02h12'13"
Au moment de l'arrivée du CdB dans le poste, la situation visible et audible ne reflète pas ce que l'équipage a vécu jusqu'alors.
Tous les éléments sont réunis pour créer une situation incompréhensible, aggravée par l'affirmation du PNF « On a tout tenté », sans pour autant dire ce qu'ils ont tenté et pourquoi ils l'ont tenté.
Le PF est resté sur le schéma mental de la survitesse, le PNF prend l'autorité et réagit à l'alarme STALL en appliquant la poussée CLIMB. Le CdB a une attitude passive.
A cet instant, il ne peut être établi que l'avion est rattrapable.

02h12'13" à 02h12'26"
Le CdB n'a pas de diagnostic de la situation, et ne peut répondre au PNF qui le sollicite.
Le PF retrouve une attitude (assiette et inclinaison) qui lui fait dire qu'il a le contrôle de l'avion.
L'alarme STALL a un fonctionnement inversé pour une vitesse mesurée inférieure à 60kts.
La tension devient perceptible au sein de l'équipage.

02h12'26" à 02h12'44"
Le stress intense devient perceptible, la communication au sein de l'équipage utilise un vocabulaire non conventionnel qui ajoute à la confusion.
Les informations visibles valides sont rejetées et le segment perception-diagnostic de trajectoire en montée n'est pas partagé par le PF.
Le fonctionnement inversé de l'alarme de décrochage ajoute à la confusion sur l'action sur le manche et le pilotage de l'avion.
La loi ALTERNATE 2B reste active hors du domaine de vol connu limitant l'action de la gouverne de profondeur et perturbant la stabilité longitudinale naturelle.

02h12'44" à 02h13'18"
La tension devient plus forte au sein de l'équipage où la synergie est absente.
Le PF manifeste son désaccord sur les remarques de ses collègues sur son pilotage. Il alerte sur l'altitude en descente.

02h13'18" à 02h13'59"
La divergence de diagnostic est manifeste. Le PF alerte sur le fort taux de descente, le PNF est orienté sur le bon fonctionnement des commandes de vol, le CdB ne prend l'initiative à aucun moment.
La configuration de l'avion ne permet plus la récupération du décrochage.

02h13'59" à 02h14'27"
Dans cette phase ultime l'équipage réagit conformément à l'alarme de proximité du sol.


The report also includes a CVR transcript. Noteworthy: even the jucidial report respects the privacy included in european reglement 996/2010.
BTW, there is no meaningful difference between the BEA's and the judicial's reports transcripts.

[jcjeant]

Where are they?
The two missing parts:
Report part 2
http://aerofuites.com/exp-jud-juin-2012/D06716-179-D06716-356-rapport-definitif-expertise-techniqu.pdf
Technical annexe
http://aerofuites.com/exp-jud-juin-2012/D06717-a-D06718-rapport-definitif-expertise-technique-du-29-.pdf

[Organfreak]

PJ2 sez:
hi gums;
Yes, the gang's all here, but only momentarily!

No I'm not!

[Chris Scott]

Quote from CONF_iture:
"Full CVR audio does not belong to the public but it belongs to the front crew.
Full CVR audio + full FDR data have to go to the pilot at the same time they go to the investigative body + manufacturer.
If I die on my job, I want my wife to have my data.
Too painful it will be for her to listen to the tape, but I have Friends I trust she can provide the information to, making sure every one is keeping honest in his duty."


While I heartily agree with all that as an aspiration, is it all established in law?
Are you allowed to share them with others, and are there any restrictions on that?
And, in the event of your death before your receipt of it, does your next-of-kin inherit your rights?

[HazelNuts39]

jcjeant,

Thank you for the two remaining parts.

[CONF iture]

http://www.pprune.org/7746564-post1025.html
In a few thoughts :
Law is not necessarily to protect the little guy.
To keep our institutions honest is the role of the citizen or the little guy.
The media should play that role too but belongs now to the big guy ...
What happened on my flight deck has to go to the investigative body and the manufacturer which makes sense, but what could justify full data is not going to me as well or the one on my short list ?

[vapilot2004]

It would be easier to understand your discourse, if you could tell us what those areas are.

Sorry HN. Did not see this right off. I was not ignoring your question, which is reasonable.

First, let me say I have gone through the type course and had plenty of simulator time and more on the A320 series not that long ago. The AI FBW is an ingenious system and while I will admit not being a fan going in, I came to appreciate the immense amount of very clever programming that goes into making the FBW system a transport pilot's best friend 99% of the time. I tell you this so you know where I am coming from.

One of the things I discovered during my 'indoctrination' was there are times when you are not fully in the loop and have to trust the process as you monitor. This is not a knock on the AI FBW system. It is a symptom of the larger problem of automation in general and it cuts across aircraft brands and types. Pilot’s groups and unions have known about this for over two decades, but as an industry, we are just beginning to understand the need for a tighter coupling of the man machine interface and the importance of keeping current our manual flying skills - getting back to the basics. Some never left that place of surety, particularly the old timers amongst us, but many of us could easily be caught in the trap of not “using it” and “losing it.”

I believe the evidence produced so far clearly indicates the crew of AF447 were out of the loop from the start, and it appears they were caught in a trap of mostly their own doing, however I also strongly feel their aircraft or training , most likely both, let them and their passengers down in what turned out to be the worst way possible and it was the combination of these factors that led these otherwise competent pilots, down the garden path. I strongly feel the BEA should have explored this aspect of the accident further. The report should have included data and analysis of the several documented instances of unreliable airspeed and known pitot issues across the fleet to better understand how this critical sensor failure manifests itself in real life.

Three paragraphs on, and finally to your question HN. What more could the BEA have done in preparing the report, outside of the above sentiments I offer? The published DFDR traces are entirely too coarse at roughly 30 seconds per ½ to ¾ of an inch. By statute, the DFDR on this category aircraft is required to provide a sampling of the pitch, yaw, and roll inputs and their corresponding control surface positions at a minimum rate of 2 hertz, with 4hz being standard for these channels. That's 2 to 4 samples per second. As to the other available channels, the raw CG trim fuel data might be interesting to know. An additional set of engine parameters beyond N1 might be useful. The AOA and airspeed plots are a mess as are the control input traces, the former group mostly due to the erroneous data but all three groups further muddled by the coarse scale that was chosen. The EFIS state is marginally presented, but a bit of a mystery remains as to exactly what was seen in the cockpit that night and when.

I see a renewed interest in the CVR transcript. This is one of the most sensitive areas of accident data. As far as I know, nearly all ICAO member countries share similar legal requirements for the handling of the CVR audio and transcripts. Other than photographic or descriptive evidence of human remains, the CVR audio is the most protected data set of the investigation. The BEA seems to have done a reasonably fair job in sharing this most sensitive part of the accident investigation.

[bubbers44]

va 2004, you have figured it out. I thought only old pilots like me could do that. Good for you.

[HazelNuts39]

vapilot,

Thanks for your reply.
The report should have included data and analysis of the several documented instances of unreliable airspeed and known pitot issues across the fleet to better understand how this critical sensor failure manifests itself in real life. BEA's Interim Report no.2 provides a detailed analysis of thirteen preceding UAS incidents that were adequately documented. The judiciary experts have interviewed the pilots involved in some of these incidents and describe how those pilots perceived the situation.

The main body of the BEA final report contains some very detailed graphs of the areas that really matter. Other DFDR data are shown on a smaller scale in the appendix and include pitch, roll and yaw input and control surface deflection at the recorded sampling rate, which is equal to or higher than the values you mention. If you have difficulty with the graphical scale, use the 'zoom' function of your pdf viewer. The graphs do show all relevant parameters in sufficient detail to permit an understanding of what took place.

There is no indication of any abnormality in the engine behavior, nor of the pilots even looking at the engine parameters. So how would additional engine parameters contribute to a better understanding of what happened?

EDIT: As to AoA and airspeed being a mess - the plots show the actual data points as they were recorded, without any filtering or 'interpretation', except that the graphics software added a thin line connecting each data point to the next.

The report also shows, to the extent possible, what was to be seen on the EFIS, for both pilot's stations. What was actually seen by the pilots can only be derived from their comments as recorded by the CVR and documented in BEA's report.

[jcjeant]

BEA's Interim Report no.2 provides a detailed analysis of thirteen preceding UAS incidents that were adequately documented. The judiciary experts have interviewed the pilots involved in some of these incidents and describe how those pilots perceived the situation.
Yes indeed
Question:
Is that those documented reports were in the hands of AF before AF447 accident and if so .. is that the AF pilots were briefed ?

[HazelNuts39]

.jcjeant,

it's all in the final report of the 'coll`ege d'experts'

[jcjeant]

HazelNuts39
.jcjeant,
it's all in the final report of the 'coll`ege d'experts' Yes I know also that .. and that is why I wondered why your answer to Vapilot was incomplete
Vapilot
Thanks for your reply.
Quote:
The report should have included data and analysis of the several documented instances of unreliable airspeed and known pitot issues across the fleet to better understand how this critical sensor failure manifests itself in real life.
HazelNuts39
BEA's Interim Report no.2 provides a detailed analysis of thirteen preceding UAS incidents that were adequately documented. The judiciary experts have interviewed the pilots involved in some of these incidents and describe how those pilots perceived the situation.As the reports of the experts show that AF did not give alot of importance to these documented reports and did not follow a timely manner has its pilots before the AF447 accident.
Error of judgment ?
Poor risk assessment ?

[HazelNuts39]

jcjeant,

my discussion with vapilot is about a "multitude of unpublished areas" in the BEA reports. Unless vapilot tells me otherwise, I think my reply to his last post was sufficiently complete.

[Clandestino]

Error of judgment ?
Poor risk assessment ?

It's hindsight being 20/20. It's quite ignorant pointing to precursor incidents as proof that the big one could have been predicted and prevented. It is not as if Thales probes getting blocked was the only problem on 330/340 fleet. In real life hundreds of incidents happen every day, just a few developing into emergency and very, very small fraction of them leading to disaster. Out of thirty-something UAS in 330, only one involved damage and injuries.

I also strongly feel their aircraft or training , most likely both, let them and their passengers down in what turned out to be the worst way possibleWhat are you basing your feeling on?

I strongly feel the BEA should have explored this aspect of the accident further. In what manner?

The published DFDR traces are entirely too coarse at roughly 30 seconds per ½ to ¾ of an inch.So? Do you believe higher resolution would yield completely different picture?

the raw CG trim fuel data might be interesting to know.Why? It is perfectly clear aeroplane responded to control inputs, too aft CG would accelerate demise by a second or fraction thereof but it would be pretty irrelevant in the grand scheme of things.

An additional set of engine parameters beyond N1 might be useful. What for? Engines work as advertised. What difference would oil quantity or ITT margin make on stall event?

The AOA and airspeed plots are a mess as are the control input traces, the former group mostly due to the erroneous data but all three groups further muddled by the coarse scale that was chosen.Actually reading the report would help to dispose of this nonsense. There are three different timescales included in the report.

Law is not necessarily to protect the little guy.Since this is not law but aeronautical forum, I'll concentrate on flying aspects: little pilot guy is best protected when he knows and understands his aeroplane and medium he is traveling through. Failure to do so more often causes his demise than anything else.

What happened on my flight deck has to go to the investigative body and the manufacturer which makes sense, but what could justify full data is not going to me as well or the one on my short list ? If we take for granted that you or anyone on your short list can indeed do more for aviation safety than officially appointed expert teams, well then there really would be no reason.

[jcjeant]

Out of thirty-something UAS in 330, only one involved damage and injuries.So if it is so rare this kind of accident .. I wonder why there was so much noise around this accident .. why change the probes .. why procedures were reviewed .. why new training .. for a case so commonplace
Why all the fuss about ?

If we take for granted that you or anyone on your short list can indeed do more for aviation safety than officially appointed expert teams, well then there really would be no reason. Empowering censorship (because it is one of the powers of the BEA) may appear plausible for some case
Nevertheless we will never know the justifications for censoring .. they can be legitimate or illegitimate
This is a double-edged weapon

[DozyWannabe]

@jcj : The Service Bulletin mandating the replacement of the Thales AA probes was in effect *before* the AF447 accident. If I recall correctly, the accident aircraft was scheduled to have the work done in the following month or two.

[Clandestino]

I wonder why there was so much noise around this accident ..Mostly made by those handicapped by inability to understand the circumstances leading to it. Why do they feel the need to parade their ignorance is beyond my powers of understanding.

why procedures were reviewed To improve them. Something that happens when old ones are discovered lacking. Usually we don't need crash to do it, incidents serve as reminder well enough. Now for sciolists: there were crews who ignored stall warning as spurious and kept the attitude; there were crews that pulled but quickly reverted to push when warning went off. AF447 was the only one that both pulled and ignored stall warning and in that matter it was unique among the A330 crews but not among other crews flying "classic controls" aircraft who performed such a feat before them.

Empowering censorship (because it is one of the powers of the BEA) may appear plausible for some case Do you care to provide reference to your interesting viewpoint or you'd rather have us believe you because you said so?

Nevertheless we will never know the justifications for censoring Probable cause: imagination running wild.

[jcjeant]

Do you care to provide reference to your interesting viewpoint or you'd rather have us believe you because you said so?Already discussed extensively
BEA has censored the CVR transcript .. what is in the public domain is a censored version
Why some parts are censored ?
Because it is the prerogative of the BEA
Thus the BEA can censor it considers necessary .. and did not provide a justification
Why BEA censorship that part and not another .. nobody can tell ...
By definition .. censorship is hiding or removing certain things ...
The truth can not accommodate things hidden or secret
When things are hidden or secret .. the consequence is imagination running wild .. that can be avoided by exposing the all truth .. not by censoring ..

[DozyWannabe]

@jcj:

As I'm sure you well know, "censored" is a loaded term, usually with negative connotations.

The fact is that every CVR transcript ever released into the public domain as part of an accident investigation report has been abridged to some extent. This is - and has always been - true of reports released by not just the BEA, but also the NTSB, ATSB, AAIB and TSB Canada to name but a few. If you consider what the BEA has done to be censorship, then you must also conclude that the transcripts released by all of the above have also been censored.

Personally I think it's the wrong term to use, due to the aforementioned negative connotations. The reason all transcripts are restricted to the portions that are relevant to the conduct of the flight is because the pilots' unions demanded it as part of the agreement to making CVRs mandatory on transport-category aircraft.

[Organfreak]

Dozy remarked:
Personally I think it's the wrong term to use, due to the aforementioned negative connotations. :mad:

I disagree. The term is entirely accurate, no matter the intent. IMO, any removal of any information is to diminish our understanding of the conduct of the flight. I am normally quite sympathetic to the valuing of privacy, but in the case of transporting large numbers of people, I'm afraid that privacy isn't at all appropriate. The World has an abiding interest that ought to trump everything else. (I doubt I'll get much agreement on this from a buncha pilots!)

In the case of a private entity passing judgment on the causes of a horrible crash, I believe that some members of the public feel the need to draw their own conclusions from all of the information available. There will always be some people with some sort of "prurient interest," but I think we need to set that aside in the interest of total transparency.

And...this "prurient interest," which is seldom discussed in depth, is natural, AFAIC, on the basis of: there's a natural curiosity about what it's like to prepare to die in a plane crash. Sorry to rip the lid off a jar of spiders.

:uhoh:

[jcjeant]

Hi,

I disagree
I agree

[DozyWannabe]

:mad:

Don't shoot the messenger!

In the case of a private entity passing judgment on the causes of a horrible crash

The investigatory agencies aren't private entities though, they're usually governmental agencies with a charter that explicitly denotes their independence from the regulator and other government bodies and are ultimately accountable to the taxpayers (many of whom are also the travelling public).

The limits on the use of CVR data for public dissemination haven't changed in four decades, and it wasn't the investigatory agencies that set those limits. As a result, words to the effect of "The BEA is censoring data" are misleading, because the BEA, as with other agencies, has to abide by limits that they themselves have no control over.

[AlphaZuluRomeo]

I feel like quoting wise words from a few pages back, in an attempt to -perhaps- stop the hamster's wheel:

The only inference I can draw from this current discussion is that a few forumites are in effect demanding that the BEA should release the CVR sound track in its entirety, so that it can be broadcast on the www for public judgement and therefore, inevitably, prurient entertainment. Unlike the investigators, they seem to care little of the human consequences, and would carry no responsibilty for them.

They represent the school of the blame and shame culture - the modern equivalent of those who relished the spectacle of the guillotine, or pelted with rotten eggs the petty criminal in the stocks. To them an investigation is a tool for litigation; not for learning. Finally recovered from the trauma of realising that their crazy assertions about the demise of AF447, and the conduct of the search, were discredited, they employ weasel words to imply that the BEA is conspiring to pervert the cause of justice for the deceased.

Those who constantly protest for the truth, but deny it even when it is staring them in the face, include the usual suspects. They know who they are. They have never worked in an airliner cockpit, nor on the bridge of a ship, and appear to have no experience or even understanding of the balance between authority and responsibility in a safety-critical operation. Just as well, for their cavalier indifference to rational thought, combined with obsessive attention seeking, would be a lethal combination. Their constant carping has slowly betrayed their agenda, which even they no longer believe to be compatible with the established facts.

The truth is that no degree of revelation would silence their accusations of tampering of the data and other evidence, and it is impossible to prove a negative. Releasing the CVR audio channels for public consumption would be an immoral act. It would also persuade most flight crew that installing cockpit videos would be an intolerable step. Their arguments are not worthy of consideration.

[Organfreak]

Dozy:
Don't shoot the messenger!

I wasn't. It was just a little joke, since we have a "censored" emoticon. Regardless, if you are "the messenger," you're delivering fact. But in this case, it was opinion, not fact.

And, thanks for the lecture; I'm well aware that BEA is not technically a private entity, but its processes and machinations are, by definition, private, and that's what I meant.

As for the subsequent reprinting of Chris Scott's diatribe, I didn't like it the first time and I like it even less this time. It's full of uncharitable characterizations and motives-not-in-evidence as to those of us who feel that something may be withheld. Just for one example: "The truth is that no degree of revelation would silence their accusations of tampering of the data..." Nonsense.

[DozyWannabe]

Regardless, if you are "the messenger," you're delivering fact. But in this case, it was opinion, not fact.

The opinion was sandwiched in between facts - namely that the restrictions on CVR publication are outside the control of the BEA, and thus the notion that the BEA are themselves responsible for the redactions for their own motives is incorrect.

And, thanks for the lecture; I'm well aware that BEA is not technically a private entity, but its processes and machinations are, by definition, private, and that's what I meant.

No more so than any other accident investigation agency.

As for the subsequent reprinting of Chris Scott's diatribe, I didn't like it the first time and I like it even less this time. It's full of uncharitable characterizations and motives-not-in-evidence as to those of us who feel that something may be withheld. Just for one example: "The truth is that no degree of revelation would silence their accusations of tampering of the data..." Nonsense.

Actually, some of the people and organisations he's referring to are indeed that partisan - though I'm pretty certain you yourself are not. For example, the French pilots' union SNPL are well known to have an agenda to harm Airbus at any opportunity - an agenda that dates back to the stink their FE contingent kicked up when Airbus announced the A300 would be available with a two-person flight deck back in the early '70s. You can trace almost every Airbus-related "controversy" in France to the actions of that union and their lawyers - including the notion (for which there is no evidence) that the BEA are somehow involved in deflecting criticism.

The crux of the matter for me is that no person or organisation would stand to benefit from withholding information in that manner. The fact that the BEA report mentions non-optimal aspects of the aircraft design as well as the way it was operated by the airline and the crew means it's likely that both Airbus and Air France will end up paying damages. The A330 is a successful type - its continued existence, operation and sales will not be harmed no matter what was in the BEA report. Is my reasoning in this flawed?

[Turbine D]

Organfreak,
"The truth is that no degree of revelation would silence their accusations of tampering of the data..." Nonsense.
Google TWA800, look at all the blog sites that continue to this day and then tell all, you still believe it is nonsense... Imagination, leading to fictional conclusions, often outruns reality and facts...

[Organfreak]

I hear ya, Mr. D.

One of the reasons I don't pay much attention to conspiracy wackos is that (I think) most people are too stupid to actually pull off a complex conspiracy. (Pilots excepted, of course.)

[jcjeant]

TWA800 is a school case for conspiracist
The report's conclusion was that the "probable" cause of the accident was an explosion of flammable fuel/air vapors in a fuel tank
The key word in the report .. after 4 years of painfull investigations .. is "probable" :8
This leaves doors wide open for anyone with imagination :)

[piper-28]

Exclusive: Joint Airbus & Boeing flight test lecture - YouTube

[Lonewolf_50]

Are the slides posted on line?

[henra]

One of the reasons I don't pay much attention to conspiracy wackos is that (I think) most people are too stupid to actually pull off a complex conspiracy. (Pilots excepted, of course.)

Where is the 'I Like' button? :cool:

I couldn't have put it any better.

[PJ2]

Lonewolf_50, here's a link (http://media.aerosociety.com/news/2013/03/22/airbus-and-boeing-deliver-joint-lecture-at-raes-hq/8172/) to the RAeS site discussing the preso...haven't had a chance to examine it for links to the actual ppt.

[Lonewolf_50]

I got to their site, but I don't see them posted yet. Maybe too soon.

I did get to listen in to about the first 25 minutes of the presentation. I think I'll save the whole thing for when I am watching a bit of golf this weekend, with the sound off, and thus multi task. At an hour 40, it's a bit of a time investment.

[Turbine D]

PJ2,

Thanks for the link, Watched the entire presentation last night, it was worthwhile to gain the understanding of stall recovery. I explored the site but couldn't find the actual charts (pdf) from the video. However, your previous postings of the SIM stall exercise you did on stall recovery was confirmed by this video presentation in my mind. TD

[thermostat]

A wonderful presentation by both Airbus and Boeng. It was enlightening, informative and to the point. A big thanks to both companies for doing this.

[RetiredF4]

A wonderful presentation by both Airbus and Boeng. It was enlightening, informative and to the point. A big thanks to both companies for doing this.

How will it be used? Will the management and bean counters have a look at it and change some programs? Will the findings and conclusions find their way into procedures and the training of those?

Will aircrews look at it and learn from it?

[Owain Glyndwr]

Franzl,

Your post leaves me wondering ...... I heard four flight test professionals describing how they go about a delicate task that must be approached carefully. They were talking to the Flight Test Group of the RAeS, and I think their purpose was to inform not teach. No lessons to be learned but some questions answered.

Moreover, I suspect that if those much maligned management and bean counters approached those guys and suggested they change their procedures to save a few dollars or euros they would be rapidly and forcibly told where to go and what to do when they got there.:D

[fizz57]

The key word in the report .. after 4 years of painfull investigations .. is "probable"

That's the conspiricy theorist's answer to scientific professionalism.

When all you have are a few smoking (or in this case salt-water corroded) bits of wreckage there is no way you can be 100% definite about any conclusion - even the 737's rudder hard-overs can only "probably" be all associated with a malfunctioning PCU.

Unfortunately, those with axes to grind - or lawyers - interpret this as a license to let their imaginations run riot.

[RetiredF4]

Owain Glyndwr

Franzl,

Your post leaves me wondering ...... I heard four flight test professionals describing how they go about a delicate task that must be approached carefully. They were talking to the Flight Test Group of the RAeS, and I think their purpose was to inform not teach. No lessons to be learned but some questions answered.

Moreover, I suspect that if those much maligned management and bean counters approached those guys and suggested they change their procedures to save a few dollars or euros they would be rapidly and forcibly told where to go and what to do when they got there.

Somewhat unsure where to place your kind reply.

I wonder myself, in the briefing was nothing new on the planet, mostly stuff what expierienced old school pilots learned about stalls amd falls from the beginning regardless whether it was civil or military. Was this knowledge completely lost and has to be invented again?
How long will it take to make the findings and results available to the line? And still i´m concerned, that it will again end up in some fixed procedure without transfering te knowledge which led to the developement of said procedure.

[PJ2]

franzl;

The notion of "amoral calculation" was discussed in Diane Vaughn's work, "The Challenger Launch Decision: Risky Technology, Culture and Deviance at NASA". The notion expresses the common worry and perception that "bean-counting, profit-seeking managers" will drive instrumental priorities in spite of clear evidence of outcomes in terms of deviance, failure, incidents and accidents.

Vaughn found that contrary to her beginning premise (that managers at NASA were expressing an amoral calculation in their operational work), there was almost no evidence of cynical wrong-doing motivated by profit but only the best intentions towards the goals at hand. From Vaughn:
Repeatedly, I was struck by the difference between the meaning of actions to insiders as the problem unfolded and interpretations by outsiders after the disaster. As I gained an understanding of cultural context and chronological sequence, many actions, much publicized and controversial, took on new meaning. Incidents that when abstracted from context contributed to an overall picture of managerial wrongdoing became ordinary and noncontroversial. For example, after writing a 1978 memo objecting to the joint design, Marshall engineer Leon Ray helped develop corrections to the joint that assuaged his concerns, leading him to believe that the design was an acceptable flight risk. Ray's memo became part of the official record creating the impression that managers had been overriding engineering objections for years; his subsequent action did not. Now alert to the importance of relocating controversial actions in the context of prior and subsequent actions I expanded my focus beyond its restricted attention to rule violations. (Vaughn, p. 60) The other notion that Vaughn pioneered (but which we in this business are familiar with by other names) is the "normalization of deviance". For those new to the notion, one way of expressing the meaning is, the reducing of margins of error in standardized proven systems because the standard can successfully be reduced while maintaining sufficient margins of error. (There are other ways of expressing this of course!).

So rather than nefarious activities behind engineers' backs, most managers could claim to be onside with the safety people but they also knew that they had to be mindful of schedules, budgets, regulatory affairs, government politics and public perceptions. As you would expect these are very bright and aware people but none of that guarantees that phenomenon such as normalizing standards through "reasonable justifications" is the right thing to do. Often it is seen as "amoral", and calculated towards pedantic goals only in hindsight.

The recent review of the "courses of action not taken" regarding in-orbit video and photographs of Columbia concerning the wing damage, (initially discussed in papers in Starbuck's and Farjoun's "Organization at the Limit: Lessons From the Columbia Disaster") is one such clear example - a sad one showing that NASA had not fully learned the lessons of Challenger ten years earlier.

If I were looking for a place in organizational dynamics that could lead to present circumstances, (your point about "mostly stuff what experienced old school pilots learned" etc), I would view a relatively unquestioned stance towards the privileged place of technology in present-day operations. Such a question is not informed by what we could call the "fiscal discourse" yet it appears to mimic the effects of "bean-counting" priorities. That way of putting the question leaves the issue open to recognition of the good that technology contributes positively, while examining the permissions we grant technology in terms of the relinquishing of control, all of which can lead to an inappropriate reliance and which, as we know well, will (not may) let us down at the most critical moment.

I think the industry has been changing for some time now - ie., returning to the old ways while keeping technology, and the RAeS lecture is recognition of this and as such is indeed information in aid of this change.

That doesn't mean that pure bean-counting decisions which dismiss safety in favour of commercial gain aren't made. I've seen it happen, (despite senior managers seeing the FDA data.) However from what I saw the other side is by far the weightier one!

I know from conversations with those doing the work, (I'm retired) that this knowledge has been in the simulator scripts and training courses for some time now. I'm less confident that an abiding mild skepticism regarding automation is making similar inroads but I think it is moving inexorably in that direction.

[Owain Glyndwr]

Franzl

I wonder myself, in the briefing was nothing new on the planet, mostly stuff what expierienced old school pilots learned about stalls amd falls from the beginning regardless whether it was civil or military. Was this knowledge completely lost and has to be invented again?
How long will it take to make the findings and results available to the line? And still i´m concerned, that it will again end up in some fixed procedure without transfering te knowledge which led to the developement of said procedure.

I agree that it was mostly well known facts, but although I count myself "a practitioner skilled in the art"(of aerodynamics) I still learned some new things about how stall testing is done these days. I don't think it is a question of knowledge being 'lost' - flight testing is a continuous process and what was being presented was more a statement of the accumulated wisdom of the two flight test departments. Seems to me that your concerns really relate to the transmission of this expertise to the guys who actually fly these machines every day.

That said, I'm not sure how much line pilots need to know about actual flight test stalling techniques but of course the descriptions of typical stall and post stall behaviour were and are relevant.

I'm shooting my mouth off here, because I have no experience whatsoever in this area, but to an outsider it seems that there is sometimes an important gap in the information trail from manufacturers' flight test expertise through their training departments to airline training departments to line pilots. Not just on stall behaviour; there are other examples where inherited wisdom was not passed on.

Pilots will no doubt be able to put me straight on that ;)

[RetiredF4]

It was not my intention to downplay the important work of test flight departements, though posted in this thread my focus was more what it will provide to the end user.

We are in full agreement on your following statement.

Owain Glyndwr

.......... but to an outsider it seems that there is sometimes an important gap in the information trail from manufacturers' flight test expertise through their training departments to airline training departments to line pilots. Not just on stall behaviour; there are other examples where inherited wisdom was not passed on.


@ PJ2 I see your points, now tell me what will change and who will initiate the change? there are lots of saying like ..... my company is doing that and that .......i practice that and that.... and so on. Schouldn´t those necessary changes in training and qualification be regulated and monitored to a necessary standard?

[PJ2]

franzl;
Re, "now tell me what will change and who will initiate the change? there are lots of saying like ..... my company is doing that and that .......i practice that and that.... and so on."
I guess I'm not quite clear on what you're searching for. Isn't that how change occurs and isn't this what has been occurring for a long time now? A discussion on the elixir and ultimately the industry's addiction to automation, like any such human behaviour, requires a pretty firm intervention which does not occur everywhere, or at once.

I apologize for the length of these posts - it's pretty dry reading I'll admit but the answers to the kinds of issues you're raising are complicated and can't be captured in a nut-shell, so to speak.

Re, "Schouldn´t those necessary changes in training and qualification be regulated and monitored to a necessary standard? "

Regulators are necessary certainly, but notably and notoriously lag behind such needs as are being expressed here. The aviation industry, people, companies and groups on the other hand take individual initiatives to increase flight safety where the need is indicated and do so proactively (Safety Reporting systems, Flight Data Monitoring & Analysis), and obviously reactively.

This is where change comes from - small steps, quietly taken.

Rarely does the industry wait for the regulatory intervention before taking action. For example, as I have pointed out a few times, in Canada under the CARS, training, demonstration and checking a candidate's response to the approach-to-stall is not required in PPCs on fly-by-wire aircraft. I have offered the thought in discussions that this makes no sense, first because there is nothing magic about fly-by-wire, which can stall an airplane just as easily as hydraulically-powered controls can and second, even a protected airplane can stall, as we now know, (so the elixir of automation was reinforced in at least one country's air regulations). The assumption in this regulation regarding PPCs is that somehow, fbw "protects" one against the stall, which we know is not true. It is software add-on "protections", (for gums, "limits"!), that are at work in the B777 and Airbus types.

But I know for a fact that practically-speaking, in Canada the approach to the stall has been and continues to be trained, practiced and checked in PPCs in 'Airbus aircraft and all other types, (at least at the carrier with which I am familiar) notwithstanding the absence of the requirement to do so.

Another example - the FAA's "minimum hours" rule came a long time after the industry began dealing with issues which arose out of inexperience, poor training/checking and the worst aspects of poor implementation of SMS Programs, (where in this regard the regulator discovered that oversight was still necessary because such implementations are very complicated and "self-reporting" needs a lot of maturing before the regulator can step back).

Within months of the AF447 accident, I know that some airlines were ensuring that crews were being exposed to, trained and checked in these procedures; - the manual-handling issues were quite rapidly brought to the fore as well.

My thought in the post above was first to deal with the notion of the bean-counter-as-amoral-calculator, not that such behaviour doesn't exist - it does, but that it is not the norm; most people working in a system intend to do their very best within the context in which they are employed. The point is, the causes of aberrant (meaning unsafe or leading to risk of unsafe outcomes) do not necessarily always come from parsimony but from misunderstood goals and contexts. As an airman you already know how aircrews can and do react to penny-wise / pound foolish cost-savings.

Like you I agree fully with Owain's statement that you've quoted but those circumstances don't arise out of bean-counting behaviours. Such failures to communicate seem to come from a lack of appreciation of what information in flight test work may or may not be useful and required information for daily line operations. While complex, airline operations are very much like rabbit trails - extensive but narrowly-focused on the needs of the daily operation. Recurrent training is expected to look after the contingencies and abnormalities. With few exceptions this was my experience and although not universal, is largely the case in the west.

So, it isn't as though the regulator shouldn't be setting the standard; it's just that the standard is often set long before the regulations formalize and standardize the standard...so to speak, (my brother who is an engineer always observes that that is the nice thing about standards...so many to choose from).

[john_tullamarine]

Thread #11 starts here (http://www.pprune.org/tech-log/511119-af-447-thread-no-11-a.html#post7760634)