Another Air France incident

[guclu]

Incident: Air France A319 at Sofia on Oct 16th 2012, rejected takeoff from taxiway (http://avherald.com/h?article=4579eb0f&opt=0)

Rejected takeoff from twy.

[stakeknife]

Surely not!!

[fireflybob]

Well done to Sofia Tower for being alert to stop it happening.

[Lonewolf_50]

I found the overhead picture of Sofia's airport to be of interest. My initial impression was "well, it is as wide as a runway ... easy mistake to make ... "

This post a bit further down by one of the commenters there cleared up some of my confusion.


Absolutely correct. Before the airport expansion completed in 2007, the Taxiway H used to be the runway. After building the new runway 09, it became the taxiway. However, up to now there have been no accidents of this kind for the last 5 years or so and Sofia Airport sees quite a lot of aircraft daily

What crossed my mind is the question of how often this crew had been to Sofia, and what went on during the pre-flight and pre-taxing crew briefings, what NAV/Chart data they had to hand, etcetera. I envision a less than joyful "tea and biscuits" session on return to home base.

On a more positive note, the alert controller caught them in time to avert anything worse than a red face or two. :ok: Well done.

EDIT: looks like firefly bob got ahead of me in the kudos department. :O

[NigelOnDraft]

If you really want to stop incidents/accidents such as this you close as many holes in the cheese as possible, not just blame one party.

Given an "unusual" taxiway / runway width / layout as here, one step would be not to issue a takeoff clearance until an aircraft has crossed H?

[Finals19]

It would be interesting to see the AF checklists and what the line up checks include. Some kind of FMS and navaid integrity cross check would almost definitely be included(?) to cross check departure position.

That said, the failure to verify visual cues (runway intersection holding point signage etc) is rather worrying.

[Hotel Tango]

The markings are quite clearly those of a taxiway and not a runway which, since it was CAVOK, makes you wonder what was going on in that FD? Amazing!

[blind pew]

Somebody must have spiked their claret:ok:

[glad rag]

N.O.D. Yes, that is a very. good. point.

But it would some require some kind of secondary cross-check to ensure the crews didn't just give it lip service...

[Spitoon]

But it would some require some kind of secondary cross-check to ensure the crews didn't just give it lip service...Isn't that what professionalism is about?

[Admiral346]

The layout is not that unusual, a lot of airports have done the same reconstruction. Nice, for example, and they should be familiar with that one.
Toulouse and Lyon also have wide parallel taxiways, and runways without centerline lighting. Charles de gaulle is not a very structured airport, you really have to pay attention with all the K1 K3 and so on.

[transilvana]

Well, we have paphos, on the last years is not unusual to land on the taxiway.

[groundfloor]

Airbus check:make sure the a/c symbol on the ND (Nav Display) is joining the runway on lining up. If not: wrong runway, taxiway or map shift.

[NigelOnDraft]

The layout is not that unusual, a lot of airports have done the same reconstruction. Nice, for example, and they should be familiar with that oneExactly. And how many (attempted) to take-off / land on the wrong runway? The answer is not "none" ;) We certainly had specific airfield notes warning against it. And why have NCE invested in the world's largest flashing 'X', that you can see from 20K' :eek:

[root]

Whether or not Taxiway H used to be a runway is irrelevant in this incident. The visibility was at 4000m so that's another excuse out the window. Runway 09 is equipped with HIRL and CL. There would be no trace of those on H. Never mind the fact that all the crew would see is a yellow line with (perhaps?) green taxi lights instead of a plethora bright HIALS cross bar lights due to a significantly displaced threshold on RW09.

What most likely happened is crew fatigue, complacency or just plain not paying attention. Perhaps they had more pressing matters to discuss? I know I'm certainly not holier than thou when it comes to that, especially with crews I'm very familiar and comfortable with.

You can blame the airport layout, ATC or invent MAP cross-check SOP's.
Or you could properly picture what exactly you should be seeing on line-up and then look out the window to verify that.

[Basil]

Just in from pub so usual caveats but -
Now that there has been an incident, what measures should be taken to ensure that this strip is clearly and unmistakably marked as a taxiway.
Would there have been a problem if they'd continued takeoff on the taxiway?

[fireflybob]

Potentially this type of incident could happen to any airline - as long as humans are involved there is a capacity for error. Fortunately in this case the error was picked up by ATC.

Of course we should continually seek ways to prevent future incidents such as lighting, signage etc and even better or more relevant training.

I would ask the question "Are you perfect?" - I suspect the honest answer would be "No" - then who are you to judge imperfection?

Am in no way making excuses for this crew. I am sure they are mortified by such an error.

I see this type of incident as a "system failure". Who are we to judge when we do not have any facts about what was going on at the time?

Rather than damning any airline or individuals we need to ask how we can prevent these incidents from ever occurring again?

[DownIn3Green]

Fench says it all...one language in the cockpit, English on the R/T with ATC, and looking forward to that split of wine with the crew meal...

[FRying]

Sofia airport is VEEEERY confusing. I, myself, felt very incline to taking off from this very same area only a while ago. It took my colleague's clear mind to get me back on the right path.

[AN2 Driver]

TWY H at Sofia is clearly marked as a taxyway, yellow centerline line, blue lamps and IIRR a green centerline lighting.

The way it got done was really the only way to build a proper new runway at the time, as any other upgrading / renewal of the old runway would have meant to close the airport for a few months.

[sooty3694]

The layout is not that unusual, a lot of airports have done the same reconstruction. Nice, for example, and they should be familiar with that one.

I assume you have not been there. I am sure many would disagree with your statement that it is not that unusual a layout. What has Nice got to do with it - comparing them is like comparing chalk and cheese? The taxiway in Nice is not TWICE the width of the runways, and neither is it between them.

And why have NCE invested in the world's largest flashing 'X', that you can see from 20K'

Not of any relevance to the topic we are discussing. The larg flashing X at Nice is ONLY used when there is WIP on one of the runways. It is NEVER used to highlight a taxiway.

The markings are quite clearly those of a taxiway and not a runway which, since it was CAVOK, makes you wonder what was going on in that FD? Amazing!


I guess as someone who never makes mistakes, you never amaze yourself!


That said, the failure to verify visual cues (runway intersection holding point signage etc) is rather worrying.

Runway incursions and events like this happen almost every day somewhere on the globe, and yes it is rather worrying, but pointing accusing fingers at one crew, or suggesting that they were not attentive or didn't have (or follow) appropriate SOPS is not the way to prevent future occurrences.

Potentially this type of incident could happen to any airline - as long as humans are involved there is a capacity for error. Fortunately in this case the error was picked up by ATC.

Of course we should continually seek ways to prevent future incidents such as lighting, signage etc and even better or more relevant training.

I would ask the question "Are you perfect?" - I suspect the honest answer would be "No" - then who are you to judge imperfection?

Am in no way making excuses for this crew. I am sure they are mortified by such an error.

I see this type of incident as a "system failure". Who are we to judge when we do not have any facts about what was going on at the time?

Rather than damning any airline or individuals we need to ask how we can prevent these incidents from ever occurring again?




= the most sensible post IMO

[Hotel Tango]

I guess as someone who never makes mistakes, you never amaze yourself!

Very defensive retort Sooty. Yes, I do amaze myself at times. Luckily not whilst in command of an airliner full of passengers. This could have been catastrophic. They are supposed to be highly trained professionals and whilst mistakes can occur due to sometimes understandable (though not acceptable) mitigating circumstances, on this occasion they must have been mightily distracted on this clear day with the actual runway clearly visible next to them. That they went as far as commencing the roll on a clearly identifyable taxiway is defenseless. Would you have felt the same if it had been catastrophic and your loved ones were on board?

[framer]

Sooty and Firefly are onto it, probably two minutes before the incident that crew could never have believed they could make such a mistake and would also have been "amazed".
Now they know the reality. Stay humble.

[Sciolistes]

I've seen one of these incidents in action. A 737 lined up on a big fat taxiway with a 777 rumbling towards it from the far end. Fortunately, ATC noticed and cleared the 777 off the taxiway and pointed out the error to the shocked crew.
...probably two minutes before the incident that crew could never have believed they could make such a mistake and would also have been "amazed".
Now they know the reality. Stay humble.
Well said Framer. The reality is perfectly competent pilots make these errors. Therefore, in my view, it can happen to any other competent pilot.

[Hotel Tango]

The reality is perfectly competent pilots make these errors. Therefore, in my view, it can happen to any other competent pilot.

Well, if that's your standard of competency it's time for me to stop flying! In my book a COMPETENT pilot should not make such an INCOMPETENT mistake as this.

[framer]

Well, if that's your standard of competency it's time for me to stop flying! In my book a COMPETENT pilot should not make such an INCOMPETENT mistake as this.
That's just it though HTango.....they do. It's often not the bottom dwellers who sneak through their sim checks by the skin of their teeth that make these cock ups. It's Jo Bloggs who has been perfectly competent for years. Accepting that you could make the same mistake is half the battle.

[WHBM]

As this incident took place at 0356Z in mid-October that is surely before daylight, so the visual references are only going to be the lighting and illuminated signage, not any perception of concrete which "looks like" a runway.

[Heathrow Harry]

dawn was around 05:45 Zulu today in Sofia so yes - dark

[Admiral346]

I assume you have not been there. I am sure many would disagree with your statement that it is not that unusual a layout. What has Nice got to do with it - comparing them is like comparing chalk and cheese? The taxiway in Nice is not TWICE the width of the runways, and neither is it between them.

I fly to Sofia regularily. It has never occured to me, that it would be a difficult airport to taxi. I have been there in summer and winter, in sunshine, TS, snow, day and nighttime.

What does Nice have got to do with it? Well, maybe you haven't been flying for too long, but that southern runway is new, and the parallel taxiway used to be a runway...

[KingAir1978]

taking off in an easterly direction, sunrise at rougly 5:00Z, so just before sunrise, but looking in an easterly direction into haze (vis 4k...), possibly after a nightduty... From a taxyway that used to be a runway... swiss chees, holes...

[sooty3694]

What does Nice have got to do with it? Well, maybe you haven't been flying for too long, but that southern runway is new, and the parallel taxiway used to be a runway...

Nice since 1979, but whether its layout is new or old I still do not see the relevance.

The old northern runway at Nice is indeed a taxiway now, but it is not twice the width of one of the present runways, and neither is it situated between the two active runways.

[sooty3694]

Well, if that's your standard of competency it's time for me to stop flying! In my book a COMPETENT pilot should not make such an INCOMPETENT mistake as this.

Hotel Tango, I am struggling to comprehend your post. Are you suggesting that because you have such a high level of competence you are you not going to make a mistake of this magnitude - or any mistake?

Or perhaps you are suggesting that there are competent mistakes and incompetent mistakes - and that the only mistakes you make fall into the competent category?

If you don't believe that you have the potential to succumb to any of the psychological factors that effect human performance, then I would suggest you haven't learned much about flying yet.

[Shore Guy]

Honeywell's "Smart Runway" system would have prevented this and many other similar events (Comair Lexington comes to mind).

[reverserunlocked]

I thought AF had RAAS on their fleet? A rather loud 'on taxiway, on taxiway!' would get their attention. The sooner RAAS is mandatory the better.

[framer]

I' m not saying you're wrong Jo, but can you give us some facts and figures on that or is it just your perception?

[lomapaseo]

Maybe an understandable incident in isolation ... but how long must PC dictate that the elephant in the room be ignored? - The conspicuously disproportionate number of serious incidents that occur amongst French operators, notably AF.


Please provide data including which numerator and denominator you propose to use to justify such a wild claim

Ignore the data on PPruNe since we tend to make elephants out of ants behind our keyboards.

[camel]

Maybe time for s/e asian countries to 'ban' AF? ok that might be a bit harsh (at the moment) but lets be honest their safety record is not exactly great is it ?given a choice as a passenger i would certainly avoid them like the plague.

[cactusbusdrvr]

Our airline has added a runway verification line to the checklist just before departure (below the line on the taxi check). We verify the runway listed in the FMC and verify the actual runway outside the window.

The reason for the addition was the number of runway specific RNAV fixes that we fly to on departure. There were some incidents of ATC switching departure runways after pushback and the crews not entering the new runway and new SID transition. But the runway check also serves to capture this type of error.

[KAG]

Downin3greens: Fench says it all...one language in the cockpitOne language? So at least speak it correctly, French, not Fench.

Those kind of mistakes are happening everywhere in the world by any kind of crew.

I admit I myself once took off from my friend' backyard... I was flying an Ultra Light though... ;)

A reminder: a taxi briefing should be done before the take off briefing, hope it helps...

[FBW390]

Joe: but how long must PC dictate that the elephant in the room be ignored? - The conspicuously disproportionate number of serious incidents that occur amongst French operators, notably AF.

Incidents with non-AF? Which ones? Please explain!

Accidents and incidents with AF? Plenty :, Concorde in 2000, Toronto A340 (aircraft destroyed), Rio-Paris A330 in 2009 228 fatalities

[fox niner]

Air France's safety record is worse than what it seems. Some accidents do not pop up in the statistics because:
1. there were no fatalities
and
2. the aircraft was not scrapped, but eventually returned to service.

You will only be able to find any information on certain incidents/accidents when you specifically know what you are looking for.

Notable examples:
- Runway overrun on 13th June 1995 at Delhi Airport
http://www.airdisaster.com/photos/airfrance/1.jpg

- Tahiti aquaplaning 12th september 1993
http://www.airdisaster.com/photos/f-gita/1.jpg

- Serious incident during takeoff run at Lagos, Nigeria, 11 jan 2010
http://www.skybrary.aero/index.php/B773,_Lagos_Nigeria,_2010_(RE_HF)

[FBW390]

About the AF A319 in Sofia:
I understand small mistakes but this is a HUGE mistake that could have made an accident (if small aircraft on twy H).
They were at night? So the runway lights should be clearly visible and WHITE; not blue and green as on a twy. Of course we don't know everything about this serious mishap but the result is that with a vis of 4K at night they made this HUGE mistake: it could have killed many people; remember SQ 744 in 2000 in Taipei: 83 fatalities when taking-off from a closed runway in bad weather. I heard the CVR: no taxy briefing, no correct runway identification at line-up; same with Air France that day in Sofia?

[camel]

oh well..i guess the crew will just get called in for a cold coffee ,quick Gitanes and a stale croissant without jam..then a typical gallic shrug of the shoulders (you know, that one with the special facial expression )..and back to work ..no problem eh ?:cool:

[JammedStab]

Instead of the competent/incompetent argument between the skygods and others, perhaps just best to ask ourselves what we are doing to prevent such an occurrence to ourselves at a tricky airport plus any other airport.

At my company, we are verbally saying such things as Runway 36L verified prior to entering a runway and it is also a checklist call. It is also best to check lights/paint when lining up. Blue/green lights are bad. White lights are good for confirming on a runway. Yellow paint bad, white paint good. Threshold numbers the best.

Plus we use the localizer(if possible) and heading for runway confirmation on low vis takeoffs.

If it is not your SOP, I'm sure most of it can still be done by silently.

[guclu]

I think the problem is not comlplying with standard procedures.

Because like most of you say I am sure they had the rwy confirmation rule, they did know the white light or blue light meaning etc. etc.

[jcjeant]

The problem with Air France is that when a pilot is incompetent .. one in the other seat is too!
AF has two scheduled flights per day in Sofia
The runway is 5 years old
What should be more for don't confuse runway and taxiway ?
Answer:
Two competent pilots

[Piltdown Man]

Yellow paint bad, white paint good.

Ever been to Norway?

Come on chaps, let's get rid of pointless additional checks and crap arse-covering briefings. Just do the basics and do them properly. Briefings should be very simple - a basic intent and then highlight of the BIG risks. In the past I have been bored rigid with ludicrous drivel which near enough goes down to the colour of the bloody ink and the thickness of the paper.

Less is more (from the KISS principle).

[camel]

would be interesting to know what the French media make of AF nowadays , any ideas ?

[fireflybob]

Piltdown Man - with you all the way there!
My attention isn't long enough for these parroted briefs!

[FBW390]

Jammedstab: very good point. If it's not in your SOP still do it in your head: yes.
Every available clue should be used to check and re-check you will be leaving from a runway and the correct one.:ok:

[Roger Greendeck]

Not sure what AF are using but there are a number of aircraft and or operators that have a long checklist which gets run during line up (my current one has nine checklist items).

This is the problem with adding a check each time an error happens. You end up missing the forest for the trees. Instead of concentrating on the big picture you are trying to complete a checklist correctly.

[Clandestino]

Well, if that's your standard of competency it's time for me to stop flying! In my book a COMPETENT pilot should not make such an INCOMPETENT mistake as this. If all the hints from the very beginning of man's conquest of air were not enough to some to recognize this to be so so untrue that it borders with pathologically romantic, then official adaptation of TEM a couple of years ago definitively should have been.

However, I would be first to admit that there are legions of PPRuNers absolutely incapable of taking off from wrong runway or taxiway.

[Say Mach Number]

Our airline now say taxying is a 'critical phase of flight' i.e. sterile cockpit applies - no non operational chat.

Would love to hear the cockpit tapes from AF at Sofia see how what the chat was prior to take off.............

Distractions have been proven to be one of the biggest factors in accidents/incidents.

Eg Spanair MAD jumpseating cc in cockpit and non operational chat prior to take off. Not necessarily the cause but a fact. No flaps and the rest is history.

[4Greens]

The reference to the website 'Accident rates' includes a page 'some airlines with zero accident rates'. It doesn't include Qantas! Enough said.

[AlphaZuluRomeo]

Not quite enough, if I may...

Qantas has no known fatalities since 1951 (which is impressive, I grant you).
But due to its age (again, impressive), one can't hope to write "Qantas is an airline with zero accident rates" and be right about it. ;)

[4Greens]

Check the actual website, it gives dates.

[AlphaZuluRomeo]

Sorry, no date limitation on the said page. This one includes dates only for airline start. ;)
Dates are on the other page, to level how rates are calculated.

[4Greens]

Regards. Fly Qantas.

[Matey]

Quantas has historically flown a predominantly long haul operation with long periods of low risk cruise and significantly less exposure to the higher risk take off and landing phases of flight. It is not, therefore, surprising to find them at the better end of the league tables. Lies, damn lies and statistics etc.

[Hotel Tango]

and it's QANTAS.

[TooLowFlap]

I thought AF had RAAS on their fleet? A rather loud 'on taxiway, on taxiway!' would get their attention. The sooner RAAS is mandatory the better.

I'm not sure, if AF has retrofitted RAAS on their fleet. Even if they did so, isn't the "on taxiway take off alert" optional?

http://www51.honeywell.com/aero/common/documents/egpws-documents/raas-documents/custwrksheet-documents/ATR-RAAS-Worksheet.pdf

(see 5.4)

[managespeed]

the aural msg ON TAXIWAY is triggered at 40 kts on the ground and they stopped at 30 kts...
the RAAS is installed on the entire fleet since a couple of years now

[Yaw String]

"Are you ready for a threat and error brief."...."Chickens can fly...and we are human, and can fly much better than chickens..HOWEVER...Chickens were meant to fly!"

Yes...lock me up if I say that before every departure..and of course, I don't.
.
Point is, from the moment we enter our cockpits, we are out of our natural environment, so we must ALL be very careful....from the 20k veteran to the .2K newbie.

Am 55, and it has never been more true than today,Sacrebleu!

[A-3TWENTY]

Despite this incident , I think their safety Record is increasing.At least the still Did not destroy sny plane during the last 12 monthes.

[paull]

I think that rather than express the fatality rates as a % of average as they do on that site, a better way is to test statistically the statement:

"They are fundamentally the same", is it possible that the differences are caused by chance?

In this case, the chances of AF being just unlucky are about 4.5% , Turkish 3%, Aeroflot about 1 in 1500! So, yes a concern.

You cannot really say much about the rest, BA,LH, Alitalia & Iberia seem to have dodged about 5 between them, but even then there is a 1 in 3 or 4 chance that they just got lucky, and if you make your own luck, let us hope they continue to do so.

RyanAir & Easy - looking good but to quote the Chinese "too soon to tell".

Still, fatalities data is a bit of a blunt instrument, I would rather deal with how often the holes nearly lined up if I had to make a meaningful ranking.

[eagle21]

The French BEA released their final report in French (later released English version) concluding the probable cause of the serious incident was:

Inadequate monitoring of flight parameters, which resulted in the crew not noticing the autopilot had disconnected and a deviation from assigned altitude after reflex actions at the controls.

Incident: Air France A343 near Guadeloupe on Jul 22nd 2011, rapid climb and approach to stall in upset (http://avherald.com/h?article=44280b2a/0006&opt=0)

[bricquebec]

Between January 1995 and July 2010 I flew 1.463 flights as a passenger. 998 long haul, 465 short haul using a multitude of different carriers worldwide. Only one long haul (Concorde ex JFK) and one short haul (an internal connection) were AF. I am an admitted francophile, but my instinct always steered me well clear of AF and the unprofessionalism of the cc. If I had doubts about the cc, I guess that influenced my sub conscious view of those on the fd. CDG would have been as convenient start/end point for me as LON. Just a personal view, guys.

[BOAC]

Quote:
The pilot flying realised at that point they were at 38,000 feet and queried the pilot not flying whether they weren't assigned to FL350.
- can we believe we are reading this? What are these crews doing with the instrument panel in front of them?

[ATC Watcher]

The pilot flying realised at that point they were at 38,000 feet and queried the pilot not flying whether they weren't assigned to FL350

BOAC : you are right but they got what they asked for :
1) PNF presses autopilot disconnect
2) PNF pull stick back 75% for 6 seconds
3) a/c climbs with 2000ft/min initially then pitch increases to 12 degr up and the vertical speed increases through 5700 feet per minute,

This not automation / Airbus computer logic that put the aircraft at 38.000 ft at Mach .66 with 12 degr nose up...

[Wizofoz]

Quantas has historically flown a predominantly long haul operation with long periods of low risk cruise and significantly less exposure to the higher risk take off and landing phases of flight. It is not, therefore, surprising to find them at the better end of the league tables. Lies, damn lies and statistics etc.

How far back counts as "Historically"?

They have operated the largest domestic and regional fleet in Australia for the last 22 years!!

[jcjeant]

- can we believe we are reading this? What are these crews doing with the instrument panel in front of them?

1) PNF presses autopilot disconnect
2) PNF pull stick back 75% for 6 seconds
3) a/c climbs with 2000ft/min initially then pitch increases to 12 degr up and the vertical speed increases through 5700 feet per minute,

Scenario "a la AF447" .. or better ... "a la Air France"
How far back counts as "Historically"?

[A4]

What's most alarming after reading the report is that this happened post AF447. If you haven't read the above link, do. It makes alarming reading - scary.

Have AF actually implemented any upset recovery training program? Judging by the response of this crew the answer is no - or they were asleep during the training. Pitch of 12 degrees nose up at FL370! 6000 fpm ROC. Checklist to see if AP is engaged :ugh: Attempted PA to pax by PF during upset.......

It is difficult not to come to the conclusion that there is a serious culture/arrogance issue within AF. What's the saying..."a rotting fish stinks from the head". Does AF need a top to bottom audit like Korean had a few years back?

If this was a far eastern outfit everyone would be screaming "ban them". This is the flag carrier of the 2nd (?) most prominent country in Europe - that is really worrying.

[jcjeant]

It is difficult not to come to the conclusion that there is a serious culture/arrogance issue within AF. What's the saying..."a rotting fish stinks from the head". Does AF need a top to bottom audit like Korean had a few years back?They had already one few years ago (Rapport Colin) pointing many of the problems discussed here and in AF447 case
But .. seems it was useless ....

[g109]

This is truly unbelievable what incompetent pilots work for air France.
No lesson whatsoever has been learned.
Something fundamental must be going wrong in this company.
If things are not changed there drastically and quickly more lives will be lost.

The question is not if they will have another crash, but when.

Can anyone enlighten us how air France works internally?

I think they should be put on the EU no fly list, as they are CLEARLY UNSAFE.

I Would certainly never fly with them

[Duffb]

Another, again..?

[framer]

In the FDR print out it looks to me that the FO nose up side stick coincides with an actual pitch down of the aircraft body angle almost perfectly. Was the PNF simply reacting instinctively to a sudden pitch down of the nose?
Standing by to be corrected.

[camel]

I hear that way back in the 1960's the word on the street was:

'Take a chance ...with Air France' .

some crystal ball they had then eh?

But then again they also had BOAC: 'Better on a camel' :ouch:

[HazelNuts39]

Was the PNF simply reacting instinctively to a sudden pitch down of the nose? Only the PNF himself is in a position to correct you. PPRuNers can only speculate. A note in the report says the airplane encountered a head-on gust of 25 kt, followed a few seconds later by an upward gust of 35 kt. The airplane probably pitched down in response to the upward gust. The PNF's instinctive reaction may well have been in response to the combination of overspeed warning, g-force and pitch-down movement.

[ATC Watcher]

Hazelnuts39 :
The PNF's instinctive reaction may well have been in response

An " instinctive reaction " ? and when you are PNF ?

[framer]

ATC Watcher.... If I am PNF and the aircraft manoeuvres abruptly it is definitely my instinct to correct/control by applying control inputs regardless of who is PF.
The same is true for TL movements. As a rule I normally remember who's job it is prior to doing that though. But the instinct is still there.

[ATC Watcher]

Framer : Interesting. I am not expert on Airbus CRM, but in my world ( smaller A/C and ATC) we are taught and we teach not to follow instincts but rather procedures. Also that one person, and only one is controlling and giving orders , especially during an abnormal situation. But maybe AF SOPs are different.

In this case we do not have the CVR , so we do not know if the taking over by PNF was perceeded by words like : "I have it" or " You take over " .
But knowing how the BEA writes reports, if following the pilots interviews,they would have been convinced that this had been the case, they would have mentioned it in the report. They keep refering to PF/ Pilot monitoring.

A few points on the report indicate a rather assertive PNF: the taking over the PA address to pax after the falling handset ( but again we do not know , that might have been preceeded by an order from the Capt) , the manual A/P disconnection and and the subsequent side stick inputs.

But surprisingly , the speeds selection , the later disengagement of A/T and pushing the thottles to TOGA were performed by the PF, so it may looks as if 2 people were trying to solve a turbulence/overspeed indication problem separately.
Maybe this was coordinated, I was not there, we do not have a CVR, so all this is mere speculation of course.
But this sentence on the report :102 seconds after the upset began, the aircraft was descending through 36,500 feet, the pilot flying finally notices the autopilot had disconnected and begins to operate his side stick. could indicate that the PNF actions were not coordinated with PF.

Trying to understand, not to point fingers.

[jcjeant]

Trying to understand, not to point fingers.
AF management politic = don't try to understand and want not point fingers (see Colin report -audit)
The results of this politic are commented at large in those forums ....

[givemewings]

As an interested observer of remarks here, could the following have any relevance to this incident?

Report: Two Skywest AT72 and Sunstate DH8D at Gladstone on May 16th and May 17th 2012, takeoff in night conditions without runway lights (http://avherald.com/h?article=4582c503&opt=0)

Inattention/Change blindess/Expectation bias.....

[jcjeant]

Hi,

Another event (this one was fatal) is the Bluegrass Comair accident
Comair Flight 191 - Wikipedia, the free encyclopedia (http://en.wikipedia.org/wiki/Comair_Flight_191)

[Phantom Driver]

Re: upset report; rather surprised nobody has thought fit to comment on their radar setting technique;-



During climb, at about FL180, both crew members adjusted their navigation displays to a range of 320nm, the weather radar was set to maximum gain and a tilt angle to alternate between -0.5 and -1.0 degrees.


Both on 320 nm scale? In the climb? In ITCZ territory?! I find the roughest rides when flying through those small green blobs that appear seemingly out of nowhere at close range (i.e "dry" clouds that don't reflect well on radar, but are nevertheless well on the way to fully developed CB's; a lot of unseen energy pushing them all the way up to 35,000 ft).

But on a lighter note, liked this comment,



I think the most shocking thing about this whole incident is that someone
managed to get an A343 into a rapid climb... :D

[D Bru]

Unfortunately this AF A319 rejected TWY T/0 at Sofia and the loss of separation on 7 Sept 2012 between A319 F-FRXC and B735 OK-XGB on approach to Prague, when AF F-FRXC allegedly deviated from standard procedures after way point ERASU and reportedly ended up in the flightpath of the Czech Airlines B735 already established on finals, seem to fit in with the gist of a recent investigative French TV reportage on AF:

Special investigation : Air france la chute libre : Nouveau REPORTAGE complet - YouTube

Having said that, on the LBSF incident, not necessarily to excuse the AF-crew or to say anything negative about LBSF (on the contrary, its a fine airport), but just to point out that AF normally is at parking positions 1-4 on the east-side of T2. With most of the time T/O being from RWY 27, AF would take TWY L and H to RWY 27. Or in the more rare case of T/O from RWY 09 (like in the incident flight) they will take TWY K, turn left unto H, turn right onto B and then the first right onto RWY 09. For some reason AF-1587 were on TWY J (south and parallel to TWY H, turned right onto B and (as if they thought they were on the "normal" TWY H) turned from B the first to the right, not onto RWY 09 (which from J is the second to the right), but onto....TWY H. Explicable, but not immediately excusable.

BR,

D Bru

[Jet Jockey A4]

I know there are always two sides to a story but this is unbelievable (in reference to the above video).

With the revival of the Concorde story elsewhere on the forum and the crash of 447, Air France needs to get their act together but probably won't.

It's a shame really because there are many people that work at Air France that sure seem to want to make it a safe carrier.

[blind pew]

Half way through makes the point that the Airbus chief test pilot and bosses of BEA and the DGAC were at the same flying school in 1965 together...
Another old boys network..looking after each other?

[Nordstrom]

After reading through the thread, I am sorry to say this is gross operational error.

Totally unacceptable from ATPL pilots.

Understandable if you are low time PPL pilot, and yes humans make errors, but these types of errors should not be happening on commercial flight deck period.

2 pilot crew, 2 pilots fail to recognize this? State of the art airplane. Please no excuses.

The traveling public deserves better.

[clippermaro]

After reading all your posts and pretty much being aware of what AF does offer us in terms of "incident news", let me share this with you.

On one hand; it is pretty clear Air France has a Safety Culture problem, and I ain't telling you anything you don't already know, judging by all what we see and know.

It is quite common to approach Safety Culture as an Iceberg. What you see is only the small portion of it, the rest of the incidents, problems, cracks in the safety system are usually hidden.
This is because Air France was, until recently (I think, correct me on this one, but I think 10-15 years ago the French Government held 50 % of the shares) a French company, with a French public service company culture, with French Standards and French "wisdom", French know-how and French Standards. And, guys, I am not French, but they have been building and flying airplanes for quite a while! So they are good engineers too and they know it, and unfortunately, they are not used to others telling them what to do.

However, they have failed to adapt to what´s called "Bench-marking" and "Best recommended practices", Yes in part of an obvious "language barrier", but mostly because of a cultural barrier and a failure to accept that times have changed and that standards are not only French, but worldwide. And excuse me for saying this, but standards are also Anglo Saxon, namely British (who have a very developed and mature Safety Culture), American (Trend setters and the largest regulator worldwide) and Australian, among others (Germany, Netherlands, Canada and a few others).

Air France Safety Culture needs to be completely overhauled, with clear lines of what´s called a "Just Culture" being drawn. Air France needs to change into a "world class" airline and not only a French Class Airline, as tough as it might be to accept, they will have to accept to speak better English on the radio and conform to International Best Practices, be them Australian, American, German or Ugandan.

And for this, you need to go on hard-talk with Unions and major stakeholders in the company. And on this matter, I'm not quite sure they really want to do it , so hopefully, a few guys inside AF can realize that things have changed.

Thank you and Merry Christmas to yall. Safe flying to everyone...

[Squawk7777]

On one hand; it is pretty clear Air France has a Safety Culture problem, and I ain't telling you anything you don't already know, judging by all what we see and know.


I would like to know what the "incident" reporting standard is in order to determine whether AF has a Safety Culture problem. Not defending AF, but recent incidents of cockpit fumes with Germanwings and LH crosswind landing in HAM showed me that a certain hush hush mentality exists in Germany.

Looking at my airline, we have incidents from altitude deviations (or level busts) to nav errors and runway incursions. Do we have a "Safety Culture" problem? Not according to the FAA. Sh!t happens on the line, and no one can't tell me that LH, BA, VS etc. are immune from things going wrong. It depends if and how one reports it. Since this is a mainly British/US bulletin board, I am not surprised to sense (a little) bias. :yuk:

In other words: My poo doesn't stink. :rolleyes:

[jcjeant]

Hi,

Squawk7777
Looking at my airlineJust curious .. how many passengers and crews your airline has kill during the last ten years ?

[Squawk7777]

look at American Airlines, US Air or Swiss(air) for example. Sometimes people get lucky, sometimes not. The number of pax killed does not entirely reveal the "safety culture" picture. It much more complex than that.

[autoflight]

Deaths related to flying hours may not be a perfect way to give an operator safety rating. However it is something that is difficult to hide and for practical purposes is an excellent guide.

[Squawk7777]

Not sure I agree with you on that. I had the pleasant near death experience by flying with a now defunct Mexican airline called Aerolineas Internacionales. Perfect safety record. On paper. Am still amazed that this airline did not kill any pax.

Talk to contractors that fly for a large airline out of the Korean Peninsula. Most of them will admit (after a few hops-related beverages) that they can't explain the good safety record. It's all relative.

[autoflight]

7777,
There is a lot of truth in what you say,but I did say the system wasn't perfect. The best thing about the statistical method is that fatal air accidents quickly become a matter of public record. Even those not in the business have sufficient information to avoid airlines with higher than normal deaths.

The standard of airlines that are unsafe but with no fatal accident is mostly hidden and when it isn't, it is subject to perception. Those in the business, like you and me, have more information and avoid these airlines.

[clippermaro]

Squawk7777, bull's eye on that one!

You are so right, one of the roots of the problem in AF Safety Culture is what you just said, the reporting culture. I am not so sure what their standard is over their reporting policy over there, but after working in 3 continents, they are all very different. In Asia, some airlines would require mandatory reporting of exceeding of 30 kts during taxi, with disciplinary action if it was found it was a violation, whereas in North America, it would not trigger anything, hence people would less likely report it (in North America)

This is what I mean by "French Standards". There are no more "National" standards in this business, everyone pretty much has to abide by IOSA as the golden standard of Operational Safety, and regulators are more and more aligning flaws and caveats between their regulations and "world class" or international best practices in terms of SMS, FRMS, NOSS and all the shenanigans...

[Lyman]

"Safety" is an instantaneous compilation of results. As such, it describes very little, and is used in contextual ways to placate fear, or sell stock.

In a cultural context, there are better ways to get a handle on performance, better still, to develop a culture that respects and mitigates RISK. Open and free reporting, (disclosure), internal and external, gives sufficient data to predict performance.

There is no "final score", and safety must describe 'in progress' all facets of risk.

In a setting of performance analysis, risk analysis can beneficially permeate the culture, and set a system wide 'tone'. Unfortunately, some companies manipulate, or ignore, best practice. Any principal officer who uses the word "luck" has provided a clue to the ID of such a firm...

[ATC Watcher]

Lyman :agree with you except on one thing : Luck does plays a role , always did.

Taking AF ( but only as an example , could take another airline ) was there anything controlled that prevented Toronto to become 200+ casualty instead of zero ?, same could be said for Habsheim, Brest or Pau more recently )

Been long enough in this business to know you can pile up statistics anyway you like , can hide anything you like or boost anyhing you like using numbers .

Safety is a culture, an immaterial thing, not easily translated in a mathematical formula.

clippermaro : you are right on the mark this old culture is more AF than : "French" . Other French airlines have not necessarily kept the same culture ( Air Carraibes comes to mind) although other still do.
The French air Force is not at all like this anymore since a long time .

[Lyman]

A synonym for safety is care. Luck runs two ways. If care is lacking, one hopes for good luck, and banks a greater net profit. If one takes care, there is less money in the bag.

Remember the catch phrase, "With service to London, Paris, and Johannesburg."

It is a service industry. Such a concept is open to interpretation in its pursuit.

When BA038 crumpled, there was mystery surrounding the problem. Prior to a found cause, United discovered a paper problem with fire bottle 5 in the hold of some of their 777 fleet. They ordered an immediate inspection (of all 88 aircraft) including cancellation of several revenue flights. The inspection was mundane, and turned out to be deferrable.

There are other examples with other airlines, but a pattern of care develops, and some people notice....

[clippermaro]

ATC Watcher, yes, indeed it is a matter of organizational culture rather than national culture, on the provision that National Culture does influence the organizational culture, which in turn is unique.

One thing we are all missing in the discussion here is the role of the Regulator and its interaction with AF. In all fairness and without apportioning blame or drawing conclusions, I think there are tangibles signs of either negligence from the French CAA in their oversight of AF or there is a biased relationship due to years of doing things in a certain way (i.e. retired AF employees going to the CAA and the resulting conflict of interest).

In any case, the Regulator here has a major role and has clearly not addressed the problem correctly.

Lacey was talking very properly and technically about "identifying and mitigating risks", and couldn't agree more with you in that this is what safety is about...

Years ago I remember an accident in Mexico, where a DC9 was involved in a Runway Excursion. This airline (I won't say names) was in turn in a code share agreement with a major US Airline. Because of this Code share agreement and in order to maintain it, the US investigators from this airline conducted an independent investigation of the accident and concluded something that may help your thinking on this topic.

"Although XYZ Airlines is a Safe airline, judging by the audits conducted by the National Regulator (the Mexican CAA), the US FAA, ourselves (being them the major US airline) and Insurance brokers, XYZ Airlines does not have a Safety Culture".

In other terms, you can be a Safe organization, as shown in audits, but you may not have something more important that is a safety Culture.

Think what Qantas did after the QF32 incident in SIN, they decided to ground their whole A380 fleet until the manufaturers could pinpoint the problem. This is the reflect of a mature and predictive safety culture. You can draw the conclusions on AF yourselves...

[Rwy in Sight]

I am not still sure if it relevant but I would like to put on the table the idea of national mentality of country and its impact on safety. Maybe the problem is with the French mentality rather with AF SOPs. The captain is always right and of course the union will make sure he/she is even if he is not.

[Rwy in Sight]

ZBMAN,

Having lived in both Belgium and the UK there is a remarkable difference in the mentality of higher education professional for instance. In Belgium a student takes a lot of pressure for petty issues like poor language skills on a marketing report - without mentioning the instructors had an "I am God" syndrome, and that at a national diploma level. In the contrary in the UK professors are far more approachable, if one can say so, and they tolerate arguments poor language skills if the student's idea are correct.

I was also told by a UK professor that some national mentalities believe they are have the best competence in the world and they need no coaching. Hence the comment was generated by my experience in the French education system so hardly a racism rather a justified opinion. And please note that I do speak French fluently, I do enjoy my time in France and spending time with its nationals.

I would be glad to read your definition of racism and how my comments and others to this and the others AF threads relate to it!

[wozzo]

RetiredF4,
The point is that there is a national mentality ...
I doubt there is, and the views from "outside" are mostly myths (be dissing the French I am telling a "good" story about myself and my cultural background).

But there are corporate cultures and cultures within professions. I think it's much more productive to discuss or analyze culture and "mentality" on that level.

[BEagle]

The different national cultures were explained to me by a German Airbus test pilot as follows:

"Let's say we sell the Brits, the Germans and the French the same type of aircraft. The Brits decide they want to use it for a particular purpose, so they check the Flight Crew Operating Manual for any limitations. If there aren't any, they go ahead and do as they wish"

"The Germans also decide that they want to use the aircraft for the same purpose, so they look through the FCOM for the relevant procedure. Finding none, they conclude that they cannot do it"

I then asked him "But what about the French?"

"They just say «What manual?»", was his reply!

[Squawk7777]

I am once again sadly surprised by the xenophobia by certain "so-called" professionals. According to BEagle all French pilots should not be trusted, only the Germans and the British are the supreme commanders of the skies. (Seriously mate, had a bad day, lately?) How can this board even consider using the title professional with certain comments like the above?

For all those that disagree, another indicator of pprune's xenophobia is the yearly occurring "non-English" ATC thread, that occurs with such regularity that one can sing "Alle Jahre wieder". For some odd reason, I haven't seen one yet that doesn't accuse France. It makes me laugh, since my international flights go into Central and South America, and according to most monoglots roaming this board I am gambling with my life. None of those internet tough guys seem to dare to put their logic (whether I agree to it or not) into the Latin America forum, since this is an area quite larger than Europe.

To go back to the original topic "another AF incident", it lacks any comparison to one of its European competitors since we do not have complete data of incidents (including AF). No one can convince me that airlines like LH, BA, VS, etc have perfect ops every day. Just because an incident makes a news story it does not reveal the complete picture of that airline and even of its competitors or even the national mentality. As we know, national sentiments can go both ways. :ugh: (as can luck)

Merry Christmas!

[Lord Bracken]

Plenty of BA-related incidents on AvHerald, like this one

Incident: British Airways A321 at Edinburgh on Jun 16th 2012, unreliable airspeeds (http://avherald.com/h?article=451cb9b3&opt=0)

(loss of airspeed indication in a FBW Airbus, sound familiar?)

yet they don't seem to be characterised by gross operational negligence, like those of another airline one could mention.

[Squawk7777]

yet they don't seem to be characterised by gross operational negligence, like those of another airline one could mention.

because it doesn't happen or because it doesn't get reported?

[JammedStab]

At my company, we are verbally saying such things as Runway 36L verified prior to entering a runway and it is also a checklist call. It is also best to check lights/paint when lining up. Blue/green lights are bad. White lights are good for confirming on a runway. Yellow paint bad, white paint good. Threshold numbers the best.

Plus we use the localizer(if possible) and heading for runway confirmation on low vis takeoffs.

If it is not your SOP, I'm sure most of it can still be done by silently.

Response to above.



Come on chaps, let's get rid of pointless additional checks and crap arse-covering briefings. Just do the basics and do them properly. Briefings should be very simple - a basic intent and then highlight of the BIG risks. In the past I have been bored rigid with ludicrous drivel which near enough goes down to the colour of the bloody ink and the thickness of the paper.

Less is more (from the KISS principle).


It appears that the NTSB believes as I stated above. Sorry that you and FireFlyBob disagree with them.

As a result of the investigation of this accident, the National Transportation Safety Board makes the following recommendations:

To the Federal Aviation Administration:

Require that all 14 Code of Federal Regulations Part 91K, 121, and 135 operators establish procedures requiring all crewmembers on the flight deck to positively confirm and cross-check the airplane's location at the assigned departure runway before crossing the hold short line for takeoff. This required guidance should be consistent with the guidance in Advisory Circular 120-74A and Safety Alert for Operators 06013 and 07003. (A-07-44)

[PAXboy]

But the NTSB has to produce endless lists of checks. if they go for KISS then any fault that occurs will be countered by lawyers, "You didn't tell them" eventhough the response is, "They are/were pilots, employed by a company with legal obligations blah blah." If you have laid out a zillion rules and something went wrong, "We did all that we could."

For NTSB and similar organisations, this kind of action is a SOP.

[Lyman]

Not that simple. At the outset of most great enterprise, energy is directed at performance, not product. Then the product takes precedence, then ultimately the result of product, profit.

Along the way, one ceases to do one's best, and starts to do what is necessary, then what does not draw attention to one's self.

In this vacuum of integrity, the format must produce laws, SOPS, and training to entice performance. Then the regs cease to demand performance, and simply serve as warning to meet minimums.

What follows is inevitable, blame replaces integrity, and profit replaces performance.

Culture not important? Whether corporate or societal, culture is everything.

To ignore that is beyond risk, it is an invitation to disaster.

[Gretchenfrage]

I’m on the same page as Lyman.

What’s dangerous about this territory? Safety does not care about culture or political correctness. Anything not working to enhance safety should be named, be it even social culture. If you can’t cope with that, leave this profession, because you start being a liability to safety.

We should be allowed to point out weaknesses in company culture or manufacturor design without having the usual suspects to start trash up the discussion with their lobbying bs or the other protagonists bringing up political correctness to shut it up.

Genuine safety has little to no space for such oversensibilities.


On another note, I am with piltdown man concerning the SOP/briefings overkill of today. SOPs are necessary, but not for every obvious little move in the cockpit, please.
And the modern briefings ……. They end up like life of an old couple: She’s constantly babbling the same stuff she has for the last thirty years, and he’s constantly uttering “yes dear” without listening the last thirty years.
Our constant “checked, checked, checked” is no better.

Stick to the differencies, to the unusual threats and you will have my full attention.

Stacking up the AOMs with more and more SOPs just to cover any CP or company lawyers is another nuisance. It rarely enhances safety, on the contrary, it increases workload in the cockpit and is counterproductive.
You can call a runway three times and have it confirmed by the PNF another three times, if its paired with todays a$$ covering, "standard call and don't you dare get one word wrong in the phrase" mentality there will be just as many runway incursions if your mind is stuck in the AOM instead being outside in real life.
That seems to get lost.

[The Blu Riband]

Also some airlines have a great variety of origins amongst their ranks

It would be interesting to compare the level of social diversity within AF to other european airlines.

[kungfu panda]

I don't think that it is xenophobic or French bashing in anyway to make it clear that the record of Air France over the last 30 years has been unacceptable. Air France have not matched the safety standard set by other equivalent airlines regulated within Europe. Whilst Korean air, who have a similar record, make clear steps to resolve their issues, it appears to me that Air France wish to pass the buck wherever possible.

[SylvainCap10]

Hi everyone,

Airbus is currently developping the TOS (Take Off Securing) function that will normaly prevent that kind of mistake. These incidents occur more than mentionned in medias.

This function was first implemented on A380 as an option and will be basic on A350. The aim is to give alerts - depending on the situation, Master Caution (amber) or Master Warning (red) - providing crew awareness like 'ON TWY', 'NOT ON FMS RWY', 'FMS SPEEDS DISAGREE', 'T.O SPEEDS NOT INSERTED', ect..

Let's hope that these function, which normaly must never appears, will avoid any take off in bad conditions (wrong RWY, invalidated take off speeds, ect..). However, I am wondering how is it possible to make this mistake. I did not fly into each ARPT in the world but it seems to be hard to not make the difference between RWY & TWY as lights and markings are different.

Regards

[Lonewolf_50]

About Culture:

I am probably going to say this clumsily, but here's my first stab at this.

When you are inside of your own cultural assumptions, it can be difficult to see what someone outside of your cultural assumption sees.

The "face saving as a primary norm" culture is found in varying degrees in Asian countries. It is not unfair to consider this a culturally imbedded organizatinoal norm, which unfortunately is diametrically opposed to the humility and self-examination (and admission of fallibility) a sound safety culture requires in a successful organization. Lest any of our non-Asian compadres feel smug, elements of this world view can and will crop up in organizations based elsewhere. I ddn't grow up in the great 'save face' culture but was exposed to it early, in my teens while living in Asia.

Get mad at me for stereotyping if you like, but consider that when I returned to Asia in my early 30's, I got one of those cultural appreciation briefs and training that highlighted precisely that: the whole "save face" cultural norm that was pervasive in Japan.

Hold that thought for a moment.

There is a common sub culture, or set of norms, among high perofrming, type A personalities that promotes self-belief and self-confidence. Taken too far, it leads to narcissicism, which I have seen lead to some remarkable "blinders on" failures in self-awareness. From where I sit, this approximates some of the more dangerous elements of the "save face" style and attitude.

A cliche related to this is "better to die than to look bad" attributed to fighter pilots. The related sub genre I am more familiar with is the "aircraft commander/Captain is God of his cockpit/flight deck" attitude

I was swimming in that particular sub-culture in my first squadron, about the time CRM and ACT was taking hold for serious in the USN. I think it took most of a generation to get our service to change norms and cultural assumptions, thanks in part to repeated emphasis from the highest echelons of command and a well funded safety arm. Thanks are due to the airlines and what they learned, and lessons they shared, many of which were written in blood.

I will suggest that it takes a cultural baseline of humility and acceptance of fallibility to allow such changes to come to fruition. That seems to me to be where a crucial problem in the "save face" cultural baseline resides.
It's a higher hill to climb to get to the same peak performance.

Arrogance, be it personal or cultural -- or maybe a bit of both -- is an obstacle to a solid safety culture. Yes, it can happen to any of us, anywhere. Problem is, in order to fly well, you have to have the self confidence to believe you can do something, to go ahead and master it, and to keep doing it. From self-confidence to arrogance to worse isn't that far of a progression in each step.

What I am trying to point to is that some baseline cultures (before you even get near an aircraft) present additional obstacles to the standard challenges all pilots share.

What's this got to do with Air France?

If you are inside whatever "French" cultural assumptions are, how clearly can you see your own cultural assumptions, and thus potential impacts on organizaitonal safety culture? (Fill in the blank with a given flag carrier if you like, and see how well it fits).

That, I think, is what some of the posters up above us are getting at in re culture.

OK, standing by for rocks to be thrown.

[captplaystation]

Think you nailed it. . lived 12 years in France, loved it, but I could still be frustrated by some aspects of the French mentality. I can certainly offer "being French" as a casual factor in a fairly high number of French accidents. . .. . . but, as you say, we are not allowed to say that in this blinkered/politically correct world we habitate.

[kungfu panda]

The problem for me with the clear issues that Air France have is not cultural to the country at all, but is cultural to the airline. Everything I read to do with the fatal accidents which Air france have had indicate that they can not accept any responsibility, they always try to place the blame elsewhere i.e. with Airbus, or continental.

Although I am sure that a lot has been done within the company behind closed doors to address the problems, I struggle with the fact that these are major safety issues and the problems need to be dealt with transparently. Pilots need to be able to look at Air France as an example and be able to say this is what they have done to deal with the situation. Korean air can hold its head up high and say this is what we did to create a safe airline. From what I can see at the moment Air France can not.

Having said all that the IOSA report must have been acceptable enough that other Airlines are prepared to code share with Air France. So they must basically be following international standards. I'd prefer if everything was clear though.

[fdr]

IOSA...

if the assumption of "goodness" is determined by the outcomes of the IOSA report... beware. IOSA looks primarily at documentation rather than implementation, and little meaningful correlation of actual system behaviour vs reports is conducted. What do I mean by this? The IOSA audit may find that the SMS is fine, however the incident reports do not reflect the policy of reporting vs QAR data capture... therefore there is a variation between the policy and reality/practices. IOSA AO are additionally paid by the parties that they are auditing of or for, and therefore have a dog in the fight, which is problematic. This may be well managed as a Chinese firewall, or not. The proof is look which airlines have gained glowing IOSA audits, and after you have stopped rolling around on the floor laughing, consider the implications.

[Lyman]

If IOSA are using data, documentation, and foregoing implementation and correlation, then the product is nothing more than forensics without precedent failure. Is there a better synonym for 'standards' than minimum?

It is no mistake safety is best described as cultural in nature. It begs a synthesis of performance plus, and a format that is a foundation for surpassing achievement levels that are merely "satisfactory".

Safety is organic, and wants the kind of attention given to social endeavours.

The most important ingredient, therefore, is leadership.

[Squawk7777]

The problem for me with the clear issues that Air France have is not cultural to the country at all, but is cultural to the airline. Everything I read to do with the fatal accidents which Air france have had indicate that they can not accept any responsibility, they always try to place the blame elsewhere i.e. with Airbus, or continental.


You mean like LH's crosswind landing in HAM, that the BFU later blamed on Airbus' manual?

Although I am sure that a lot has been done within the company behind closed doors to address the problems, I struggle with the fact that these are major safety issues and the problems need to be dealt with transparently. Pilots need to be able to look at Air France as an example and be able to say this is what they have done to deal with the situation. Korean air can hold its head up high and say this is what we did to create a safe airline. From what I can see at the moment Air France can not.

Define major safety issues. Luck (or the lack of) plays quite a role. If AF's accidents were cut in black and white then I would agree with you. Looking at the discussions of e.g. AF447 and the resulting changes in stall recovery procedures by many airlines and regulatory authorities it seems that the answer is not as clear cut as you would like.

Since you mention transparency: How transparent are AF's competitors? Where are those reports? What about Swiss(air)? Exempt from your statistic? Two flights I can think of with no survivors were flown by senior/training captains.

Think you nailed it. . lived 12 years in France, loved it, but I could still be frustrated by some aspects of the French mentality. I can certainly offer "being French" as a casual factor in a fairly high number of French accidents. . .. . . but, as you say, we are not allowed to say that in this blinkered/politically correct world we habitate.

Please, tell us more! Worked for AF? Seen their pilots work a flight while you were sitting on their jumpseat? Do you have copies of their SOPs? Sat in their CP's office while he disciplined some pilots? What can you offer besides a hint that you are an expert in la vie d'Air France?

Since you mentioned aspects of French mentality... What about the drinking mentality of a large island N of France? Ever considered alcohol (or the lack of) being a problem with British society? Finger pointing is easy, I could just say that many British aviators have a problem with alcohol. Fair, classy, just? Of course not. Be careful how and where you point your finger at.

B738Driver is the one that nailed it. Once again his quote:

Airbus and Boeing did not design their procedures based on societal cultures, and these are adopted by operators around the world.
Also some airlines have a great variety of origins amongst their ranks. SOP's are designed to make it work without consideration of their crews' culture.

Corporate culture is important, societal culture is not. Be careful, this is a dangerous territory! Let's remain politically correct.

[BEagle]

According to BEagle all French pilots should not be trusted, only the Germans and the British are the supreme commanders of the skies.

That was not what I wrote, Squawk7777! I said that the 'explanation' had come from a German Airbus test pilot.

But would I fly with Air France? Non! They've had too many accidents for my liking.

[JammedStab]

It appears that the NTSB believes as I stated above.

As a result of the investigation of this accident, the National Transportation Safety Board makes the following recommendations:

To the Federal Aviation Administration:

Require that all 14 Code of Federal Regulations Part 91K, 121, and 135 operators establish procedures requiring all crewmembers on the flight deck to positively confirm and cross-check the airplane's location at the assigned departure runway before crossing the hold short line for takeoff. This required guidance should be consistent with the guidance in Advisory Circular 120-74A and Safety Alert for Operators 06013 and 07003. (A-07-44)

But the NTSB has to produce endless lists of checks. if they go for KISS then any fault that occurs will be countered by lawyers, "You didn't tell them" eventhough the response is, "They are/were pilots, employed by a company with legal obligations blah blah." If you have laid out a zillion rules and something went wrong, "We did all that we could."

For NTSB and similar organisations, this kind of action is a SOP.

I wonder who has more credibility on the issue...the NTSB or a non-pilot named PaxBoy. I suggest the NTSB recommendation for verifying runways prior to entering for takeoff is a credible recommendation. Thanks for the input though.

[kungfu panda]

I actually resent people defending Air France in a way to suggest that there record is acceptable and is due to external factors, and everybody critical is Xenophopic. When I apply for a job these days outside of my own country, I have to provide a certificate of no incidents or accidents to a potential employer. I firmly believe if as individuals we have to provide these to companies then in turn companies should provide certificates with a record of their accident or incidents to passengers.

To compare Air Frances long list of passenger fatalities and hull losses with Lufthansa's failed crosswind landing or the British airways 777 hull loss (which was entirely due to external factors), or the swiss fatal accident (again entirely due to external factors) is ridiculous. Whilst risk can not be removed entirely, it should be mitigated to the maximum, and clearly Air france have failed their customers from that point of view.

List to passengers:
1. 1985- Rio de janeiro 747-200 hull loss
2. 1988- Alsace A320 Hull loss- 3 fatalities- 50 injuries
3. 1994- A300- Hijack- Hull loss- 3 fatalities
4. 1996- 747- Turbulence- 1 fatality- 30 injuries
5. 1998- Bogota- Hull loss- 53 fatalities
6. 1999- Chennai-747-200- Hull loss
7. 2000- Paris- concorde- Hull loss-109 fatalities
8. 2005- Toronto-A340-300- Hull loss
9. 2009- Atlantic Ocean- A330- Hull Loss- 228 Fatalities
10. 2011- New York- A380- Aircraft damage
11. 2012- Washington Dulles-A380- Very hard landing- Aircraft damage
12. 2012- Damascus- unecessary diversion into a War zone
13. 2012- Sofia- Attempted departure from a Taxiway

This list is just from memory, and whilst external factors may have contributed to a number of the incidents, in its entirety this list is shocking and not at all comprehensive.

[BOAC]

http://www.pprune.org/tech-log/503248-how-safe-airbus-fly-wire-airbus-a330-340-a320-family-emergency-ad.html Post#63.

[Lonewolf_50]

kungfu panda, I agree with your point on an organizational cultural matter, which any organization can be partially blind to.

[Temp Spike]

In Paris I once sat pax, (with a full load of pax), in an AF 747 as they jacked and changed a wheel assy while fueling. I could even see skydrol dripping out of the wing root fairing! Last time on AF for me.

[alcorfr]

Hi,
Air France B777 F/O here, in the company since 1998.

Facts : record of safety is really bad, on its own or compared to similar sized western companies.

Context : French culture, historically state-owned company whose management is still nowadays decided by the government, even though the state does not own the majority of stakes, several badly managed mergers leading to bitterness, civil aviation environment heavily biased towards airbus via the Dgac/government, in short airfrance was for a long time more of an administration than an airline company.

We always thought we were the best, while crashing planes.

Now, people have to know that things are really changing from the inside, and unfortunatly it took the rio to start the change :(

We, as a company, acknowledged we needed help, and asked the 'isrt' (independent safety review team) to analyse and make propositions for change :
http://epoca.globo.com/edic/687/687_relatorioairfrance_em_ingles.pdf

The team composition :
Curt Graeber, PhD, Boeing Human factors chief
John Marshall Delta safety and security chief
Geoff Sartori Quantas safety chief
and more....

They issued this report and measures are steadily being implemented, and closely followed by our pilot's union.

The LOSA (line operation safety audit) has been performed, and measures are implemented following the results.

We adopted the aiplane manufacturers SOP, we are reorganising our Dispatch, changing our charts provider, rethinking our check and training philosophy, and many other things.

The truth is, this kind of change requires at least 10 years, as it is the whole structure and company culture who are evolving (finally...and already too late for the deads in the rio and concord accident).

My message won't change the airfrance bashing on these boards, and some arguments here are justified, and acknowledged, while others are hatred, but this is the internet^^

But we know we must learn from everyone to improve, or we will disappear.

Safe flights.

[BOAC]

alcorfr - thank you for that post - it brings good news. I'm sure most of us wish you well in your efforts.

[kungfu panda]

Alcorfr- Your post much appreciated....

[Lyman]

alcorfr

You say quote...

"My message won't change the airfrance bashing on these boards, and some arguments here are justified, and acknowledged, while others are hatred, but this is the internet^^"

I think you may be surprised. Faced with good results, the carping and bashing will fade. It is my prediction. From the labor action you initiated to force the corporation to change pitot, til the present call for improvements, the pilots have carried the reputation admirably...

Reputation starts at the top, and in the front. You are to be commended for posting, and one hopes you will continue to keep all of us informed...

Leadership.....

[kungfu panda]

Just want to add that from my point of view it is not about hatred or French bashing, it is a sense of injustice. If Ryanair had the same record as Air France, they would never stay in business. If the company that I work for in China had an incident of any serious kind the CAAC would ground us, and we'd probably be out of business. From an individual point of view, if I have a reportable incident in China, I will lose my "no accident or incidents" record, which would prevent me from working. Air France though, they're able just to keep on going, allowing them to be complacent.

[Lyman]

Complacency by Air France?

More like a conspiracy to underperform.

[glad rag]

Yes, you are both, unfortunately, correct.

Even in the production halls things can be dicey; safety barriers being removed and floor covering rolled back over missing floor panels-sounds funny but try suddenly falling from deck to deck- internal access scaffolding incorrectly fastened and giving way leading to falls, safety barriers being removed and flooring put back into place despite it clearly stating on the fiche [permit to work] that it had to be there. Pity about the €30,000 electrical harness that was now stopping the floorboards laying flat....hey ho the list is, long.
Throw in semi-educated sub-sub-sub-contractors working to time constraints on pain of loss of earnings/sacking and away you go......

I don't blame the individuals though.

They are programmed from the minute they enter school about one thing only, Nation First in all respects.

I would also like to add that I have, once the effort is made, never met a more open and friendly people, those who wish to portray themselves in the best way possible.

[captplaystation]

glad rag, agree 100%, very much including the last sentence .

alcorfr. . . . .excellent news Bon Chance :D :ok:

[alcorfr]

That's funny, because i have a different take on french education and airline business.

One of the many reasons that some few pilots had a bad habit of not always strictly following SOPs (besides having TOO MANY rules to follow, which is adressed now, and poor management,) is the focus on critical thinking in public education, which may be very good concerning philosophy and politics, but needs not be systematically applied to every procedure, especially when all the data leading to the establishment of this procedure is not known... ( huh, that may appear pedant... ).

Incidentally, one most welcome change in the company culture is the openness concerning incidents, which can be perceived as an avalanche by people outside the industry.
We, as pilots, were sometimes not even aware of incidents that occured within the company, only weeks later did we learn about it.
The communication is now improving, so is the unwanted publicity, but i believe the incident rate is on par with the industry.

Thanks for your support, everybody.

[glad rag]

This appears very much as 'French bashing' to me and many will take offense to this constant cultural anti-French sentiment.

Well that's YOUR take on things.

Don't listen to those who have experienced this cultural precipice if you so wish.

[Lonewolf_50]

alcorfr, thank you for your post, and best wishes in being part of the solution and a better future for your team.

[Rwy in Sight]

alcorfr,

Just to have the courage to admit issues and implement a solution is a kind of an aspiration for all of us.

I loved your comments regarding different mentality required on education!

[steamchicken]

A question.

If AF's safety culture is terrible due to being French and a nationalised (or at least very state-influenced) industry, why does EDF - the world's biggest electricity industry by power output, which is a French nationalised industry - manage to run a huge fleet of nuclear reactors and a complete reprocessing fuel cycle with a really excellent safety record? When the UK, Japan, and the US have all failed at this at various times?

(and the States doesn't do civil reprocessing. I leave out the USSR because, well, where do you start.)

And why does SNCF, the French State Railway, manage to run the world's first and best high-speed rail network with a really excellent safety record? When China has had at least one horrible accident with an HSR, the UK and Germany have had nasty accidents with not-quite-HSR, and a lot of other countries (including the UK and US) haven't even really got it together to build it?

(Further, the French Navy operates a fleet of nuclear-powered and armed submarines and a nuclear-powered carrier. Like the RN and USN, they've never had a nontrivial accident with a nuclear ship. But then, navies usually seem to be good at nuclear, and anyway that's the military.)

This should be good news; AF can find out how EDF and SNCF do it, and copy them.

[Lyman]

Not until they decide which King to curry? Either the State, or the Partner?

Nothing worse than a confusion of leadership.

[wiggy]

This appears very much as 'French bashing' to me and many will take offense to this constant cultural anti-French sentiment. There is a lot more to the accidents involved.

Maybe, then again those Anglo-Saxons who have lived in southern France for many years are very aware that one should never ever criticise a Frenchman at his place of work (cf. my builders/architect/plumber/electrician).............lovely people socially but utterly beyond criticism - I really really hope that isn't a truely national stereotype - actually I know it isn't but it's there in some folks somewhere.

As for the success of the likes EdF/SNCF - chapeau - no honestly, it's very clever. EdF are screwing the UK bill payer because they can't do the same at home because of legislation and regulation relating to utility bill increases in France. Oh, I do get the impression some Brits in the business community simply don't give a stuff about national pride or strategic interest whereas the French do - some Brits would sell their grandmother to the best bidder, the French would keep her at home and gratefully the tax offset :E.

[wiggy]

It is off topic and yes you do digress, and yes, I've had this argument here before. This isn't about property prices in France - though they're stubbornly high :sad: .

This is about a task, any task, not being done to a previously agreed manner. In my example the builder says he's ultimately not doing it that way, because "I'm the expert , I will do what I want to do, irrespective of your input".'.. I really hope it this local trait that "I will do it my way and no criticism will be entertained " isn't a national characteristic that carries across to AF - and I really (honestly) hope you can convince me that that isn't the case and that the vast majority of AF pilots are open to criticism and questioning ........

As for my comments about Edf...je suis d'accord (See, living living here has taught me something;). Personally I do think the way French business is structured could teach the UK/Europe a thing or two about how to work the EU, but at the end of the day the Daily Mail and UKIP don't notice....

[wiggy]

Obviously we can't make assumptions that all French people are like that, and certainly not make any relation to this much bigger issue being discussed here,

Agreed 100%

Bonne annee:ok:

[glad rag]

I certainly cannot speak in the name of all AF pilots. However, I can say that the few ones I have met are really open individuals, deeply concerned by the safety culture of the airline and willing to improve the incident/ accident stats.

So Glad that you have finally "seen the light"........facts indeed.

I'll wish you all the best for '13 because we will not be communicating again.

[jcjeant]

Very brief..
The French system (culture) is (a society) based on elitism .. and not on merit
This can sometimes give strange results .. IMHO

[wiggy]

jc

Interesting, that's exactly the POV of my English speaking but French educated kids.....hopefully the strange results are good ones.:ooh:

[fafri]

I agree with most posters here about the culture problem. I'm surprised no one mentionned the incident involving an AF A320 in Muhamed V airport at Casablanca, when cleared for a visual approach for 35L, the plane landed on 35R, and this incident could have been serious. The briefing mentioned an ILS approach but the captain who was not the PF decided 4000ft AGL to perform a visual approach without any briefing while being PnF. Both did not detect (nor the ATC) the error until a RAM pilot, taxiing for 35L adknowledged the crew about the mistake. What is more alarming in this incident, and there the cultural part takes all its sense, is that the captain did not wanted to report the incident, did not protect the CVR or warn authorities. When incident was finally reported and the crew interviewed, captain stated that for him it was not worth mentionning it, if the RAM pilot did not told ATC, they would have parked without no one noticing, and the whole situation was not that critical.
Here you can spot AF captain thinking process.