Air France does a 'Memmingen'.

[Depone]

The report was posted on Aviation Herald today. Report: Air France A319 at Tunis on Mar 24th 2012, extreme rate of descent on glideslope intercept, GPWS alerts and descent below safe altitude (http://avherald.com/h?article=463d136e&opt=0)

Having done a search, I cannot find a discussion on Pprune about an event which is just as serious as Ryanair's Memmingen incident; more serious in my opinion because it displays a long period of reckless indifference to the obvious fact that the approach was never going to work.

A few quotes from the article:

"At FL207, 33nm to touch down"

"The aircraft descended through FL100 13.5nm before touchdown"

"Doing 250 KIAS the aircraft intercepted the localizer 8nm before touchdown at 6000 feet, 3400 feet above 3 degrees glideslope"

"Descending through 3550 feet, 1700 feet above glide, about 5nm from touchdown, flaps still at position 0, vertical speed -4400 fpm, speed brakes and landing gear extended"

"8 seconds after the landing clearance the first officer advised they were "a little high""

No kidding!

"a GPWS warning "Sink Rate!" sounds at 836 feet AGL, 220 KIAS, 2500 fpm rate of descent 2.5nm before the runway threshold. The GPWS calls "Pull Up! Pull Up!" and "Too low! Terrain!""

They then performed a GA and landed safely.

As for the 1700 hr co-pilot who was PM:

"He realised they were above profile and made the captain aware of this fact twice, but having been commander on other aircraft types before he did not want to encroach the captain's decisions. Due to the unusual request to do an orbit on final approach his work load got so high, that he did not think of calling for a go-around".

My bold. Is this a problem in Air France: Co-pilots too scared or incompetent to speak up?

And as for the PF:

"The captain said in his interviews, that he realised at FL100 the approach was compromised. Given the excellent weather he wanted to descend the aircraft onto the profile however".

Oh, that's ok then.

[fox niner]

Why were they so late starting their descent? Were they checking their flight scedules on a laptop perhaps?

[BOAC]

Incroyable as zey say! The reason for non-Pruning of this until today I guess is that it has only just broken into the non AF world on 14/6? Useless PF and useless PM - and that is in a two-crew cockpit. NB The PM's '1700hrs' were 'on type'.

This merely adds to the convincing belief that AF is a dangerous airline and should be placed on the list.:ugh:

[A4]

So 20,000' at 33d. 10,000' at 13d. Clean at 5d with -4,400 FPM.

Wow.......:hmm:

Is the Capt still LHS?

[BOAC]

Possibly promoted to management by now?:sad:

[Lord Bracken]

Sounds very similar to GF072 - too high, too fast, request an orbit, go-around.

[CaptainProp]

Normally...yez.. :ugh:

[763 jock]

I'm surprised he didn't try to sideslip it as well. What is going on in Air France?

[A4]

The thing that really troubles me is WHY would a professional crew who fly regularly, presumably without incident, allow such an OFF THE SCALE event to manifest in the first place BUT to then CONTINUE with it to less than 1000' AGL and only at the last possible moment conceding "defeat". We've all been high/fast at some point but COME ON - this is bordering on criminal negligence.

How can this happen in a major European flag carrier? Training? Lack of NoTech appreciation/application? Arrogance? Really, really worrying.

[BOAC]

Obviously like others they need to get onto PPRuNe and ask for advice on descent planning.......................................? a professional crew - used in its basic meaning of 'paid for work'?

[Mikehotel152]

I don't fly the Airbus, but surely Flaps 0 at 5nm when you've been high for so long is a little odd? Can't you get slow and dirty in a 'bus?

[ManaAdaSystem]

20000 ft 30 miles out should trigger a "can't be bothered to try" to start with.
Basic skills and they failed with flying colors!
This seems to be a pattern with AF.

[ManaAdaSystem]

"Doing 250 KIAS the aircraft intercepted the localizer 8nm before touchdown at 6000 feet, 3400 feet above 3 degrees glideslope"

What is the max flap speed in a 320?

[763 jock]

230 for flap 1.

[jeff64]

-> foxniner

According to the report, they were asked to start the descent early.
They selected -1000 VS.

They had a "cockpit visit" in the last minutes of the cruise, didn't do the approach brief until the start of descent, and the capt'n noticed they were still on VS only at the end of the briefing (which was approx FL200 - 30nm)

[PB4]

does AF have a 25nm / 5000ft / 250 kts kind of gate ?

[vilas]

Comparable with fatal crash of AI Express IX812 in Mangalore on 22nd May 2010. Here pilot continued with the landing and after touching down 5200ft down the RW with 2800ft remaining applied reverse then decided to go around and went downhill. Appx 40nm to touch down FL184. Joining 10DME arc 8500ft instead of 2900ft, when on localiser
4DME 3250ft.High by 1668ft.ROD 1000ft/mt.
3DME 2815ft.High by 1565ft.ROD 1260ft/mt.
2DME 2220ft.High by 1280ft.ROD 2000ft/mt.
1DME 1450ft.High by 825ft.ROD 4000ft/mt.
Very difficult to comprehend why any one would do such an approach? Does human mind sometimes stops thinking and looks for instinct which is just not there because it is not our habitat.

[fireflybob]

"Cockpit visit" - definitely a threat at that stage of the flight QED

There are times when you have to be assertive and deny any such requests (unless for emergency reasons - ie cabin crew informing etc).

I have seen pilots become so "task saturated" that they are almost not aware what is happening. This is where PNF has to assertively step in and save the day.

Psychologists have established (and subjectively I think they are correct) that when humans become "maxed out" the first "sense" which the brain deletes is that of hearing. ie the ear (physically) hears what is being said but the brain says "hey am too busy to listen to that at the moment!".

So FOs need to be trained to do a pattern interrupt. If after (say) 2 prompts there is no response it may be necessary to actually shake the other pilot on the shoulder (say) to get his/her attention and assert in command tone "Too high - Go Around" or some such thing.

In the end it all comes down to SOPs, training and disciplined operation.

[NOLAND3]

So what happened to 'Stable approach criteria?' Engines spooled, landing config etc etc.

If they had set Config 1 or higher the approach would have been even more of a mess, the engines would have been at approach idle.

[Intruder]

They never got to 500' (our threshold for VMC stabilized approach)...

[BOAC]

So what happened to 'Stable approach criteria?' Engines spooled, landing config etc etc. - as pointed out. of no relevance to this approach. Nor is the 'loss of hearing' mentioned earlier. A proper pilot should not need to wait for either PM to try to tell you you have :mad: up like that nor find you have missed a 500/1000' gate when it is glaringly obvious minutes before you have 'screwed the pooch'. As depone said "because it displays a long period of reckless indifference to the obvious fact that the approach was never going to work."

[RAT 5]

I do not understand the reluctance of crews to ask ATC assistance in such instances. "Excuse me old chap, but could we turn 90 left or right to lose a spot of height, don't you know? Perhaps even an orbit?" The neck hairs should be getting active in such a scenario. Consider the CALI crash. They were hot and high and should never have attempted what they did; a straight in NPA. That was a non-starter, so was this, so why get sucked up a cup-de-sac, only to go Oops later on. Pissing into the wind is something ill-advised. You should be able to realise it ain't going to work even before you start.

[BOAC]

You should be able to realise it ain't going to work even before you start - and as pointed out earlier, that was probably before ToD (or even, in this crew's case, when they reported for duty.......?).

[jcjeant]

To note that the CVR was erased by the crew ...
This is not the first time regarding the Air France crew and this is nothing about penalty for this kind of behavior

[silverstrata]

Wow.

But I have to ask WTF is wrong with Air France? I have seen myself this kind of approach in xxx in the Near East, and it looked like it would be great fun, if it had been in an A-10 Warthog instead of a 737. But WTF is Air France doing this for?

Air France have a downwind overrun. Then they have a team who could not understand why 20 degrees of pitch at 35,000 ft makes an aircraft go down instead of up. Then they nearly had a replay of the same incident. And now this?

I hope someone at KLM-Air France is having a rethink of training.

[silverstrata]

Rat 5

Excuse me old chap, but could we turn 90 left or right to lose a spot of height, don't you know?



I had this just this spring in xxx (wild westville in the Near East), where I was invited to make an ILS approach from 6,500 ft at 10 miles. I was incredulous and said I was not a dive-bomber, while ATC could not understand why I had refused such a lovely approach.

But I have noted at this airport that the locals take these daft approaches as a challenge, and to refuse would be to lose honour and face, and so they try to get in whatever the request. Scary stuff when you see it happening so often.

[ZimmerFly]

I think you missed a word or two from the report....

The captain stowed the speed brakes and disengaged the autopilot again at 428 feet AGL, 2 seconds later 398 feet AGL, the controller repeats the clearance for left hand orbit, the flaps are extended to position 1. 13 seconds later the thrust levers are placed into the TO/GA detent, the aircraft turns to the left and climbs to 2000 feet, then positions for a visual approach to runway 19 with ILS support and in the end landed safely.

[BOAC]

zimmerfly - indeed - I missed that too. What a 'shame' the CVR was 'erased'. The 'discussion' at 500' would have been an education, I feel.

[Private jet]

Unbelievable, thats all i can say really. 3 experienced crew that can't recognise a stall, A380 wingtip thumping a tail at JFK on a high speed taxi, a 747 that went off the side in Montreal i think and now this.......Do they still have vino with their meals? Pass the bog roll.....

[BARKINGMAD]

BOAC, agreed, maybe they should have sought help in these pages on the subject of descent planning!

Even the phrase "ENERGY MANAGEMENT" doesn't seem to feature in the plethora of FCOMs, OMs and all the other books we're supposed to consult in our attempts to arrive at the T/D point with just the right amount of energy as specified by the manufacturer, training depts, management and others.

It's not rocket science to realise that a tube full of pink quivering people, luggage, freight, fuel and its own structure weight (sorry, mass!) hurtling along at altitude and speed needs to be carefully controlled and managed to efficiently dissipate this energy until touchdown?

Yet the supposedly EASA supervised company for whom I operate has seen fit to remove the "clean" descent tables from the 'Performance Inflight' section of the QRH, see thread querying this.

Luckily I'm a G O F who has worked out his own figures and compensation factors for winds/weights etc and though my trackmiles to impact figure regularly equals the FMC computed figure to within 1%, @ ToD, said FMC regularly deviates from what I'm happy with later in the descent. By which time I have neither the capacity nor interest to attempt to persuade the FMC to "join me", so level change or V/S is regularly used to solve the problem.

At least every 5000' feet in the descent, and sometimes more often, I am comparing my estimate of trackmiles with the computation of height above T/D, IAS+weight compensation and instantaneous W/V and adjusting these to cope with ATC variations

Not surprisingly advice on descent planning is a regular query in this forum, presumably from newbies and those who are confused by the many and varied solutions offered, including by their training staff.

As rushed approaches stiil feature regularly in Airline Safety comics, the problem will not go away til it is grasped and discussed and thrashed out with some EASY method(s) promulgated by the training organisations.

Maybe we should not concentrate too heavily on the culture within AF and look to our own TRTOs who seem to have let this fundamental principle of airframe management slip through the net at best, or have ignored it at worst, so we end up with everyone doing their own thing.

As long as the FDM program demonstrates the rushed approach is still out there as a significant proportion of all approaches, then this sort of story will repeat, and maybe with more tragic results? :ugh:

[Bearcat]

I wouldn't be fired but shot for that type of carry on at my outfit. What happened a good old orbit, dogs legs etc.

[cockney steve]

As a non-pilot, I may be talking out of my khyber*...but surely,in these times of high fuel-costs, they should have throttled-back miles before and then "coasted" down, using all that expensively -bought energy , rather than "dump" it via speedbrakes, Gear-drag etc (presupposing it worked and they didn't need to burn even more on a go-around) still an expensive and inefficient way to get down.

look on the bright side....better than too low and slow! :hmm:

* Khyber Pass... = .Ass

[Capn Bloggs]

As a non-pilot, I may be talking out of my khyber*...but surely,in these times of high fuel-costs, they should have throttled-back miles before and then "coasted" down
You are indeed talking out of your @ss. ;)

To quote from Avherald:
the controller advised that the active runway had just been switched to runway 19, which shortened the flying distance to land by about 20 nautical miles.
They couldn't have "coasted" it down because they had already commenced descent.

After the runway change, provided the cabin wasn't going to be caught before touchdown, there is no value in not using extra drag to get the thing down on the ground. Coasting it down = more flying time = more operating costs.

[BOAC]

Actually, 'Bloggs' and Steve, they were indeed 'easing' it down (in V/S) and were ALREADY high when the runway change happened.

Let's face it guys and girls, FL 207 33nm from touchdown at 276kts?? This is kindergarten stuff! As someone said, it is either gross arrogance or incompetence - or, of course, both. We (I) can 'forgive' forgetting he was still in V/s while re-briefing, but.......................................

[RAD_ALT_ALIVE]

Air France = Garuda of Europe.

Oh...except that Garuda have now lifted their game and are actually a decent airline.

So sad.

(no offence meant to any Garuda employees past or present)

[Arik]

I continue to be amazed by AF's antics ...

Having been around their cadets :rolleyes:; they're certainly a different breed to other student pilots!

What angers me is the continual 'bashing' of other airlines by AF which result in EASA placing them on the black list & AF picking up their routes ... :ugh:

A case of the pot calling the kettle black I feel!!!

[F Dolarhyde]

To be fair I have seen approaches like this in almost every airline. Some end up in the news, some do not.

What bothers me the most with Air France is the denial. You will soon see a public statement from their marketing department saying that the crew "were heroes that saved a potential dangerous situation by performing a go around in the last minute" :ugh:

Look back at every accident they have had and the arrogance and the denial is stunning. THAT is why they are on my no fly list.

[4468]

I imagine the flight back to CDG was rather quiet? I am guessing the return sector is why there was no relevant information on the CVR? If the CVR was actually 'erased' they should be sacked for that alone! The rest is extraordinary, but actively hindering a subsequent investigation would be culpable, and inexcusable.

I find it difficult to comprehend how anyone can fail to 'hear' "Whoop Whoop. Pull up!"

[Citation2]

The whole system is biased by regulations, airlaw , unions etc.. Prerogatives and power granted to the commander of the flight, assume a captain sound in body and mind and not an insane totalitarian doing a one man show onboard.

It is also a cultural problem, in France the hierarchy and protocoles are very high and of a prime importance, and so is the case in the ex french colonies.

The british system is totally different where safety is paramount and the reporting policy was introduced at the very early stage of aviation. A cabin crew , f/o could report a captain if he something wrong was done , which is not the case in France and less in Air France where captain god would always be right , or any report against him would disappear...

It has to be changed from the management side . It' s not even a training related issue , if your management accepts you being unskilled you are still the best pilot as you speak french and hold a french passport.
Sad to say but Airlines do more politics than aviation

UAE identified this cultural problem and chose to adopt the british system and look at the results Emirates, Qatar, Etihad are succesful airlines .

It's not a matter of being assertive , or well trained or whatever . Any contradiction from the first officer side could have bad consequences and turned against him by the management. And NOBODY will support you in the whole management.

As a first officer in the french system you are by Default wrong.

I am not british but these are true words.

[Yankee Whisky]

Private Jet.......Do they still have vino with their meals? Pass the bog
roll.....


Egalite, fraternite et liberte.................there's your answer !

[blind pew]

Not true citation re the Brit system.
The Cvr and erase button was introduced because of the disaster that killed my mate. We erased the tape on every flight back to base. Very few would dare file a report against a captain and certainly not cabin crew.
Still existed on drop snoop as many know re the landing on fumes incident.
The only time that I witnessed a captain not wanting the tape erased was after he had set up the two first officers up!

[Connetts]

May I ask a question...perhaps questions.....

I'm a retired legal academic with some researched learned-journal publications in the use and misuse of criminal law in the context of aviation safety. I also have some hours (till ended to my utmost frustration by illness) of pilot training in Cessna 152s and Tomahawks, and I read in, maintain, and add to a modest personal library on aviation. Thus, I entertain the hope and conceit that I understand enough not to sound utterly kyber-ish -- see post 32. Forgive me for intruding, for I may overestimate myself...... I hope I'm not out of order.

The background to my question is this. While working with a senior captain with airline safety responsibilities on a jointly-written published paper, he drew my attention to a policy in which it would normally not be necessary to report a go-around if eg an unsatisfactory approach was being abandoned. His view was that this should be seen as the normal conduct of conscientious pilots from which there is, as a general rule, little new to be learned from a report. The argument, as I understood the matter, is that it serves safety better to encourage pilots to be self-critical and to go around sooner rather than later, rather than to distract them with the prospect of an invitation to tea and biscuits (is that the correct euphemism?) merely because they did what they are trained and expected to do, which is the execution of a routine, normal and safe landing.

I have absolutely no knowledge of AF's (or any other airline's) policies and so make no comment. I also do not know whether IFALPA has addressed the matter (I haven't checked).

I'm impressed by the unanimity of the reactions in this thread. I'd be interested, accordingly, to read PPruners' thoughts: is it possible that there was an initial reluctance to go around because this would have entailed exposing one's self to managerial scrutiny and critical comment? To what extent has the policy referred to above been developed and applied anywhere? What is the current general practice, or does this vary from one airline to another? Is there any prevailing operational culture which either contributes to, or detracts from, safety?

On a slightly different angle, would ATC have made any contribution to this incident, and would this have increased any reluctance on the part of the pilots to go around because a report might have exposed ATC staff?

I hasten to add that I make this enquiry purely because I have maintained my personal, "hobby" interest in aviation safety and law, and not for any formal research or publication purposes whatever. Being retired, nobody is likely to be interested in my views anyway.

[BOAC]

Connets -

is it possible that there was an initial reluctance to go around because this would have entailed exposing one's self to managerial scrutiny and critical comment? To what extent has the policy referred to above been developed and applied anywhere? What is the current general practice, or does this vary from one airline to another? Is there any prevailing operational culture which either contributes to, or detracts from, safety?

In BA, the only requirement for a 'report' was for a g/a below 1000'. It needs to be borne in mind that the two engined 'surprise' g/a is often the one that is mishandled, whereas the one in the simulator with an engine out is 'normally' properly handled. By 'focussing' via a report on the sub 1000' g/a it allows any possible lessons to be learned and disseminated. In my experience, there was never any 'tea and biscuits' following such. In any case, the BA Flight Data monitoring would 'capture' all g/as whatever the height and would have flagged up nay 'anomalies'.

On a slightly different angle, would ATC have made any contribution to this incident, and would this have increased any reluctance on the part of the pilots to go around because a report might have exposed ATC staff?

In my opinion yes and no. I think the runway change did not help, but in any case the a/c was probably more than the 6000' or so 'off the groove' for the original runway, so it would have been a 'screamer' anyway. I doubt any thoughts of ATC came into the equation.

is that the correct euphemism?

In my experience it has been 'coffee, no biscuits':)

[A4]

BOAC said.....

In my experience it has been 'coffee, no biscuits'

Do TELL! :E

Hello Connetts - of course you're not out of order!

When we talk about "go-around" this is in effect throwing in the towel - i.e. we've taken this as far as is safe - enough! This particular approach should never have even got as far as a go-around. It should have been - at the very least - a "discontinued approach" (which is one less on the scale from a go-around).

A discontinued approach is used when it is obvious that "it ain't gonna work" no matter what you try. The discontinued approach can also be sub-divided into effectively a "soft go-around" say from 1,000' to 3,000' through to an orbit at 4-5-6-10,000'. As soon as these guys got the runway change they should have realised their profile was EVEN MORE compromised than it already was - simple, ask ATC for the extra miles you now need. Don't crack your knuckles, shout "ye haa" and go for it...:ugh:

I don't think there was any concern on the part of the crew for executing a go-around off this approach and subsequent management interest - that would have indicated they WERE thinking. If they were thinking, the OFDM alarms should have been ringing in their heads - LOUDLY - and they would have taken the appropriate corrective action.

Their decision to continue and subsequent "attempt" should have career implicating consequences - this wasn't a slightly "high energy" approach it was nothing short of sheer recklessness.

We will probably never find out what sanctions (if any) the crew were subject to but the fact the event is in the public domain does raise the issue of how AF manage such episodes.

[Piltdown Man]

Phrases such as "should have career implicating consequences," "they should be sacked for that alone" and "what sanctions (if any) the crew were subject to" imply guilt and subsequent punishment. But is that justified? We have a translation of a report but none of the background information. @Barkingmad gives some clues and @Connets asks some very reasonable questions.

Working backwards through @Connets questions:

ATC: Maybe they could have helped. ATC can normally see an aircraft that is hot and high and normally drop obvious hints or, in extreme cases, give height loosing vectors. But they appear not to have done so - or did they? As I said earlier, we don't have all the facts.

Why didn't they go-around? Well, they probably thought they could make it. Why is another question. And we don't know enough about their culture to make an informed opinion. To criticise this crew to the extend that some have done on this thread I find distasteful.

I'll agree AF's record is, shall we say interesting, but the hang'em high and shoot'em brigage are adding nothing to safety. We are fortunate we don't have safety police, but I get the impression from some of the "Saints" who post here that they'd have an "Flying Court" in every airport complete with electric chair.

With any luck AF are working on trying to eliminate incidents like this but even if they succeed someone will suggest that AF are "hiding" safety reports from the regulator (whoever that is this week).

Give me more information and I might change my mind, but I'll not shoot from the hip until I have to.

[short-fuel]

Let's be factual:

-started descent too late
-"Sink rate"
-"Pull-up"
-Go-around at 398' + 1.3 sec

They should have performed a go-around a the latest at 500' and I think, I would have done it earlier.
But we all know it's easier behind the screen than in the aircraft.

Don't you think you're overeacting? The only thing they can be blamed for is the height of the go-around.


Just my 2cents.

[Jack1985]

Unbelievable, thats all i can say really. 3 experienced crew that can't recognise a stall, A380 wingtip thumping a tail at JFK on a high speed taxi, a 747 that went off the side in Montreal i think and now this.......Do they still have vino with their meals? Pass the bog roll.....

Not forgetting the A340 incident in Toronto back in 2005, Seriously this is very worrying. Is it just me or do Air France pilots who have been involved in incidents seem to discount safety in terms of landing i.e. Toronto 2005, Tunis 2012 I could go on, especially considering some pilots at AF are ex Air Inter whose philosophy was land fast and be on-time, however it seems now young/newly recruited FO's at AF are displaying little or no airmanship and worse again qualified Captains showing the same. As has been echoed for one of the worlds major airlines to have such incidents is very, very, worrying.

[A4]

Why didn't they go-around? Well, they probably thought they could make it.

Come on! 20,000' at 30d. 10,000' at 13.5d. Clean at 5d, 220 knots. That is simply unacceptable behaviour in a public transport operation. Totally solvable very early on. The ONLY defence for an approach like that is if you're on fire. I don't think the reaction on here is distasteful - in general most seem to be incredulous. The big problem for AF is they did something very similar recently into Paris with an A340.

Believe it or not, I don't like judging before all the facts are known but, as I said in my first post, this event is so off the scale outside accepted operational practice it is difficult not to be scathing.

My own opinion, and others may disagree, is that this such a serious incident it warrants appropriate sanction (not necessarily sacking) and not just a simple debrief and sim......but may be that's me. It's not about being vindictive, it's about protecting the public and making it crystal clear this will not be tolerated.

[captplaystation]

short-fuel,

they can indeed be blamed for that however I think even more concerning is that in spite of a fair amount of experience on type the Capt seemed to be blissfully unaware of the performance capabilities of his aircraft (or worse chose to ignore them ) and the First Office appeared unable to perform his primary task as "Pilot Monitoring" , that being to verbalise how screwed up the situation was becoming before it reached task saturation/quasi-dangerous levels.

[tubby linton]

The frightening thing is that the head of safety during a period when AF had multiple hull losses is now a big wheel in EASA!

[short-fuel]

Capt seemed to be blissfully unaware of the performance capabilities of his aircraft (or worse chose to ignore them ) and the First Office appeared unable to perform his primary task as "Pilot Monitoring" , that being to verbalise how screwed up the situation was becoming before it reached task saturation/quasi-dangerous levels

I think it's easy to say "they should, you shouldn't"
When your're catching up on your flightpath, as it's an uncommon situation and as we are not used to calculate path like this everyday, you can't tell immediately and definitely, "it ain't gonna work".

So basically, when I'm too high, I can't tell if it's going to work, I know it, I descent a quick as I can, and I have a fixed threshold at which I have to be either configured (1000' gear and flaps or 500' stabilised) either I go around.

I've done 20000' / 30Nm stabilized at 2000'. No big deal on that day. On another day, another wind, another weight, it couldn't have worked.

I admit it's not a bad approach, they should have gone around at 1000' or a the very last 500'. But they did go around.

[ManaAdaSystem]

I've done 20000' / 30Nm stabilized at 2000'. No big deal on that day.

No big deal? I'm sure it was a nice ride for all the punters in the back? No high speed with speed brakes and possibly gear extended and lots of vibrations and noise? A much steeper attitude than normal?

AF candidate?

[AlphaZuluRomeo]

Actually, 'Bloggs' and Steve, they were indeed 'easing' it down (in V/S) and were ALREADY high when the runway change happened.
Yep. They were 1,800ft high before the RWY change. I hope such an highness is manageable.
After the runway change, they were 8,100ft high:
Le changement de piste en service raccourcit la trajectoire d’environ 20 NM par rapport à l’approche ILS DME 29. L’écart au-dessus d’un plan théorique de 3° passe de 1 800 ft à environ 8 100 ft.

See also the graphics page 3. For those not reading french, the dark blue curve is the altitude, and the green curve is the theorical 3° slope (new runway) they were chasing.


To note that the CVR was erased by the crew ...
Do you have a source for that, or is it you "guessing" - along with a forever friendly attitude towards this particular airline - following the report stating the CVR was not available?
I can imagine other reasons for the CVR not being available, for example simply that you won't ground a plane over there following an incident with no impact on the said plane...

[mm43]

BEA's Profile Graphic with English Labels

http://oi42.tinypic.com/oa0hmw.jpg

or a larger version (http://i43.tinypic.com/35laf69.jpg)

[PBY]

I am an airbus guy. But the poor quality of training I have seen in Toulouse was mind-boggling. If Air France training bears any similarity to Toulouse training, than it is not a coincidance, how often are these guys screwing up. It is a fruit of their training and their attitude. I also added Air France on my no fly list. My company wanted to send me on Air France, I persuaded them to get me Lufthansa ticket. I am simply a nervous passenger what concerns Air France.
Have been a captain on airbus for 8 years now. This is no Air France bashing. It is a survival instinct.

[captplaystation]

short-fuel,

Don't know which type you fly, but I would suggest 5 DME /1700' high on 3 degree glide / clean (well flaps up with gear & speedbrake extended) / ROD 4400fpm/ is probably "game over" on most jet transports.

Fokker 100 was the best I have experienced for that situation, but still (!) . . . B737/DC9 no way, & I doubt that the Wunder- Bus can achieve that.

I didn't suggest that they should have thrown it away passing FL200, but . . surely 5 miles is a reasonable place to decide if "this is going to work" or not. Can you imagine anything other than a C130 on a tactical approach pulling that off ?

[FlyMD]

FL200 at 30NM was salvageable on the MD80, without doing anything radical, and you were stabilized in time. Happened to us quite a lot in the Canaries at the time, with their uhh... "special" ATC..

The only reason for NOT doing it and asking for more track miles was that the cabin crew would complain that the nose-down deck angle would make it difficult to stow the last trolleys and check the cabin..

No chance on an Airbus though..

[deptrai]

The thing that really troubles me is WHY would a professional crew who fly regularly, presumably without incident, allow such an OFF THE SCALE event to manifest

I think this question is key. Why do professional pilots, after passing multiple, rigorous selection processes, and having been been trained according to generally accepted standards, with many years of experience (in most cases decades, together) and a presumably perfect track record, suddenly behave like amateurs, and take absolutely mind-boggling actions. I don't really have an answer.

[mitrosft]

NO wonder AF has teamed up with Aeroflot in Skyteam. They are very similar in urrogant attitude to safety. After famous take off from SVO with snow on wings, a seen same last winter (this time only fuselage was totally covered, could not see through starboard windows ).

Last Sunday on FV-SU flight form KGD to SPB (ULLI) guys in A320 made final turn about 1.5 km from runway at approf 500 ft. I don't believe this is allowed in SOP, despite ATC clearance for visual approach ( I cheked later ATC live feed archive)

My choice of airline - Lufthansa, full stop.

[BARKINGMAD]

short-fuel you asked;

'When your're catching up on your flightpath, as it's an uncommon situation and as we are not used to calculate path like this everyday, you can't tell immediately and definitely, "it ain't gonna work".'

Why are "professional" flightcrew" 'catching up' on the flightpath? I thought we as a breed were selected for our ability to stay ahead of the aircraft?

"We are not used to calculate path like this everyday, you can't tell immediately.....". Then I would ask what are you doing in a public transport aircraft, allegedly in control?

As I tried to make clear in my earlier post, energy management can be reduced to SIMPLE maths, which is constantly updated by the chimp(s) in the cockpit.

As soon as ATC changed runways, the answer would have been immediately obvious that the maths/physics WOULD NOT PERMIT such a path to be flown.

ATC includes the word Control, but ultimately we as pilots have to say "NO UNABLE" to ATC, in strong terms sometimes, and accept that we're supposedly in control and they are there hopefully to stop us banging into each other and granite bits.

Either the AF crew had a macho attitude preventing this admission that they couldn't do it, or didn't appreciate their intantaneous excess energy equation?

If top dog ex-AF is now highly placed in EASA, what hope is there for a proper investigation of the CRM culture in that airline? I won't eagerly await the outcome, but refusal to travel with them will certainly work wonders as (lack of) money always talks ! ! ! !

[FullWings]

The DFDR printout looks a moderate approach in an HS121, the difference being the HS121 would have got in easily...

[overthewing]

He realised they were above profile and made the captain aware of this fact twice, but having been commander on other aircraft types before he did not want to encroach the captain's decisions.....Following the flight he believed he confused sympathy and cockpit resource management, which prevented him to fulfill his role as pilot monitoring.

This extreme politeness and unwillingness to challenge another crew-member seems to me to be similar to what we know of AF447. What's the cockpit culture in AF?

[Dufo]

Looks like CRM has a dark side which is much darker than expected.

(Too much) democracy in cockpit might work on the ground when you can freeze and reset the simulator but in critical situations when someone basically tries to kill you (and what's behind your back), other solutions could provide better outcome.

[jcjeant]

@AlphaZuluRomeo

CVR erased ?

This is in the first page of the report !

Note : les éléments suivants sont issus de données enregistrées dans l’enregistreur de
maintenance (QAR), de témoignages et des communications ATC. L’enregistrement phonique de
l’événement (CVR) n’est pas disponible.
L’équipage effectue le vol AF2184 entre Paris Charles de Gaulle (95) et Tunis Carthage.
Le briefing est réalisé à 5 h 00, le décollage a lieu à 6 h 53 min. Le commandant de
bord est pilote en fonction (PF). Note: The following information was developed from data recorded in the recorder
Maintenance (QAR), testimonies and ATC communications. The sound recording
Event (CVR) is not available.
The crew takes flight AF2184 from Paris Charles de Gaulle (95) and Tunis Carthage.
The briefing is conducted at 5 h 00, the take-off takes place at 6 h 53 min.
The commander is pilot flying (PF).Do you think the CVR is not available because someone from BEA had destroyed the CVR by mistake? :sad:

overthewing
This extreme politeness and unwillingness to challenge another crew-member seems to me to be similar to what we know of AF447. What's the cockpit culture in AF?
Report page 7
DEROULEMENT DU VOL
Le PNF a rapidement détecté les écarts par rapport au plan de descente, en a fait part
à plusieurs reprises au PF puis a renoncé à lui proposer une alternative. Son respect
de la fonction du CDB a pris l’ascendant sur son rôle de surveillance et de support.
CONDUCT OF FLIGHT
The PNF quickly detected deviations from the glide, has expressed
repeatedly PF then withdrew to propose an alternative. his respect
the function of the CBD took the ascendancy over its oversight and support.

[toffeez]

Similar to the culture in France.

Those who believe in these national comparisons will know that the French rate strongly for both Individualism and Power Distance, quite an unusual combination.

In other words big egos (I don't need help) and undue respect for hierarchy (I dare not help).

[PointMergeArrival]

Sounds very familiar. Working as a controller in Oslo I have seen a very similar incident involving AF back in 2004-2005.
We just changed runways from 19 to 01 and AF was coming in from the south. On initial call they were given information on runway change and to expect vector to RWY01R. My plan was to give them a proper dogleg to loose altitude and sufficient time to set up for a new approach.
To my suprise they requested direct 10 mile final, when they were roughly at FL180 with 35 miles to go IIRC.
I ask them if it will be sufficient distance to loose altitude and they say no problem.
I keep monitoring the flight and as they're about 20 miles out at FL 110+ I offer them a dogleg or orbit to loose altitude, and again they reply that it's not needed.
They intercept 10 DME hot and high and again I ask if they want an orbit. The reply: don't worry we'll make it.
The end result is a late go around and a crew not very happy that they now have to enter holding to sort out a problem with their flaps. (Flap overspeed, aircraft spent an extra day in oslo)
All of this is from memory and happened some years back, but it tought me to take action whenever I see something that is clearly not going to work. Since then I have on a few occations just given vectors without saying why and then given own navigation direct final when I know it's within reasonable parameters.

[goingdown]

short-fuel are you an AF pilot? If the answer is yes. RUN!!!

[LEXAN]

@jcjeant

"L'événement n'est pas disponible" does not mean that the crew erased the CVR.

According to the MEL, the aircraft is not dispatchable with the CVR operative and the breaker pulled.

So I suppose that AF allowed the return flight with the CVR operative.

[RAT 5]

I thought it had been discussed many years ago and decided that the 'macho right stuff' was not the most desirable in a commercial airliner flight deck. More years ago, operating at Schiphol. Arriving from the south west with duty landing rwy 19L and a gentle SW breeze. F/O flying on a nice VNAV/LNAV path to 6nm finals 19L. Cabin crew given 15mins to landing and all was good with life and the flying world. Being AMS, and wanting to be nice to the locals, both for noise and crews, the APP controller asked if we wanted 06 straight in. It was a clear VMC night and field insight well below the nose. Without consultation the macho F/O said yes and hauled the speed brake from its slumbers and pointed the nose a la Stuka style. Wow, I cried, as I hung from the straps. I think, forcibly, that we stick with plan A. A miffed F/O asked why? It would be alright? No? We'll save 10 mins and all the taxi time.
Well, look at the tailwind: look at the DME and altimeter; look at the perspective of the airfield and your speed; consider the cabin crew who will now lose 10 mins preparation; consider the pax staggering white faced off the a/c after their holiday vowing never to fly with us again; think of explaining to DFO why it went wrong; and think about your command assessment; and think about me having to explain why I let you do it. The answer's No.
There was some reluctance, but acceptance. OK, there were the smarties who used to descend early just incase the straight in was offered; that's OK; it's called planning. It might cost a little fuel if the longer route is required, but there are options. Sometimes I wondered if ATC at some airfields like to play a game, but our friend in Oslo seems to have an admirable duty of care philosophy. There's a time and place for 'expeditious' arrivals, but often tower does not have all the info to hand, e.g. winds, Gnd Speeds, height, a/c performance etc. They are free to offer just as we are free to refuse. I sometimes wonder why an invitation is often perceived to be a request. CALI is a great case in point and let us never forget it. Plan A was safe and relaxed; Plan B was sad. I see too often the new brigade that allow ATC to fly the a/c and not have the nouse to say "no thank you; can we do XYZ."

[Clandestino]

Do you think the CVR is not available because someone from BEA had destroyed the CVR by mistake?I think someone around here has no clue that a) CVR nowadays record in two hour loops b) if there is no limitation exceeded and everyone is happy with making return flight, it will be done c) by the time investigating bodies get notified about incident, aeroplane can have a couple of dozen hours on totalizer more than at the occurrence, which is usually perfectly legal and fine.

[A4]

With you on this one RAT - boring, predictable, safe and stress free. :ok: I declined a similar approach on behalf of the FO once (because I was concerned about tailwind) to much derision/pi$$ taking as we trundled downwind. At 30' on final, I casually pointed out the 20+ knot wind we would have had up our backside had we opted for the straight in. Surface wind was reported as "calm"......:hmm:

Save the exciting stuff for a Pitts or an Extra - not when you've got 150+ punters in he back.

[BOAC]

+1boring, predictable, safe and stress free - which does not include a screaming dive from 20,000 at 30nm, with, as pointed out, cabin being prepared for landing. No problems for the forward galley trolleys, of course........................:)

[WindSheer]

Its hard to identify whether this was poor macho attitude or weak decision making in the face of commercial pressure.
The latter is understandable to a certain degree in the modern day and can be addressed through development and maybe by taking a hard look at air frances general safety culture. However if it was a result of machoism........then i am speachless!!!

[BOAC]

Either way it says nothing for command skills!

[RAT 5]

Save the exciting stuff for a Pitts or an Extra - not when you've got 150+ punters in the back.

No problems for the forward galley trolleys, of course........................Either way it says nothing for command skills!

Been there, done that, and had lots of fun doing it. Different mind set, and I wonder at some of the cadets these days who go into airline flying because they like flying.

Upsets the Co' G and make the loops oh so difficult. Then again, in the fun a/c there's only one voice to listen to. Perhaps two; and CRM with God is optional.

[AlphaZuluRomeo]

@AlphaZuluRomeo

CVR erased ?

This is in the first page of the report !
The first page of the report doesn't state that the CVR was erased by the crew as you wrote it. And I'm aware of what is in the report, thank you, I you read my previous post.

[edit] I erase willfully my subsequent prose, as LEXAN and Clandestino already made my point, better than I did myself in the first version of this post.

Please note, jcjeant, that I do not pass judgment on the merits of taking off again without having pulled out the CVR, I just say that this scenario is not necessarily a willful destruction of "evidence" as you seem to want to believe.

[fmgc]

the hang'em high and shoot'em brigage are adding nothing to safety

Never a truer word spoken in aviation.

With you on this one RAT - boring, predictable, safe and stress free. I declined a similar approach on behalf of the FO once (because I was concerned about tailwind) to much derision/pi$$ taking as we trundled downwind. At 30' on final, I casually pointed out the 20+ knot wind we would have had up our backside had we opted for the straight in. Surface wind was reported as "calm"......

The term "I declined on behalf of the FO" implies a certain amount of narcism which is really not the done thing in aviation. I am sure that less smug phraseology and attitude would be apo pro.

[A4]

@FMGC

I can see that the turn of phrase I used comes across as smug (not the intention) and I can assure you there is nothing narcissistic about my attitude.

If you want the full version, we were offered a straight in at about 3am with strong tailwinds forecast throughout descent and already a little high on profile for the offered runway. The FO, quick as flash said "tell them we'll take it" - or words to that effect. I asked ATC to standby, expressed my concerns of energy/current profile and pointed out the likelyhood of excessive tailwind on short final. FO still wanted to go for the straight in but as Commander, and ultimately responsible, I decided we would take the normal approach. It added about 8-9 minutes to the close to 4 hour flight. IMHO that's why we are paid to be in the LHS - that's doing my job not trying to point score, belittle or be "superior".

The FO had a slight attitude problem generally (hence the sarcasm as we went downwind) and, incidentally, failed Command selection - twice in the next two years (nothing to do with me!)

The point I was trying to make with this anecdote is that there are individuals out there who just sometimes seem to not "get it". The "straight in" offer immediately becomes all consuming, a challenge and destroys their overall SA with disregard for the potential pitfalls they're setting themselves up for. Worrying.

Despite some of my comments on here, I don't subscribe to the "hang'em'high" ethos - but it seems that the airline in question IS NOT learning from previous episodes. The question is why not? Two similar events in 6 months. Is it because the info is not disseminated to crew? Is it because NOTHING is done to retrain/educate crews who deviate (massively) from SOP's? Do crews think they can get away with it without sanction? I don't know - but something's not right :confused:

[fmgc]

A4 - Fair enough.

In response the general query of your post, how do you change an airline's culture and how long does it take?

I would suggest with a great amount of difficulty and a long long time. Are they actually trying to?

[ATC Watcher]

how do you change an airline's culture and how long does it take

20 years minimum at least I would say based on my exeprience in a multinational environment .(not airline but very close)

A very surprising ( for me it was at least) feature about culture : you see older generation passing it on to younger ones who were reluctant at first, but when 15 years later those young guys are replacing the old ones,they keep applying the old culture and teach it to the younger ones below them.

In the case of AF, the problem is complicated because you have to add a internal very powerful Union plus a long tradition and culture of doing things differently.

How to do it ? ask companies who managed it successfully recently : Emirates, Etithad, Qatar, Bristow helicopters, etc.. It is painful and not very democratic.

[blind pew]

Couldn't agree more Atc watcher.
Had a post censored last week after I commented on another post which ran along the lines that the poster had a sim check in three weeks and would swot up for that rather than making a reply.
It mirrored the attitude of some of the guys in BEA in the 70s...don't open the manuals except for a sim or route check.
My final company - another culture - always be ready for any emergency - use the books for conformation.
Didn't do any revision for any checks - I just did the professional job that I was paid for.
Suspect the poster concerned inherited the old attitude - as did the crew on the BA lax flight who didn't understand the basic fuel system or those on the 777 who didn't understand the importance of the sequence of the on ground emergency items and left a fuel shut off open.
My only contact with the Air France attitude is through the French gliding clubs and is typical macho best pilots in the world....with the odd exception of a 380 trainer who goes seems to do his job very well but knows there are limitations in fighting arrogance and the system (in our club!).

[roulishollandais]

20 years minimum at least
Retroactively, and knowing that problems exists since 20 years, so the startle point was in the 70's : first oil crisis, increasing agessivity and dishonesty to have the job in Countries victims of the crisis and Franco-german airspace's "elite" :suspect: starting destroying UNO's worldwide peace culture and ICAO's global autority., replacing virility with machism :yuk:

[5 APUs captain]

I am 737 TRI/TRE and trained hundreds young CPL pilots with 250 hours only from all EU (and not only).
From my experience the kids receieved CPL in France have WEAKEST flying skills and navigation knowledges. It is just my experience, but it is too visible!

[RAT 5]

In response the general query of your post, how do you change an airline's culture and how long does it take?

I've seen it done very fast, within the 5 years, due to a focused HOT and an SOP book as thick as a bible and treated as such. That plus OFDM and many tea no biscuits. Whether is makes for better pilots, I doubt it. The allowed performance envelope was shrunk in to a vacuum packed cigarette packet. If you stayed within that you were OK, but sometime circumstances pushed you outside that and then you see guys outside their comfort zone. Not a pretty sight as the thinks bubble and ?'s mark appears as a halo and nothing happens for quite a while. The company philosophy could be, 'don't stray outside the box, and if you do get back in ASAP.' Most of the time it works, but not always. As has been said many times in many threads, the aviating airmanship foundations are not a solid as once, but how to change it? Perhaps the large SOP bible, robotic trained monkey philosophy is really a longterm conspiracy theory to dilute the need of 'the right stuff' and turn everyone into airborne bus drivers and so lower T's & C's. It seems to be working looking around at what I've departed from.
I was told it is quicker to slap restrictions on what you can & can't do than to train the crews to be able to do it all. In my early days of mostly visual flying on charters, even to ILS rwy's, the company culture was fly the very basic a/c we had. That is what all captains trained/demo'd their new apprentices, every day and you did the same. Airlines were reasonable stable in size. The massive expansion into many bases in many countries has removed the oversight of a home base training dept. Crews have come from various backgrounds and cultures. The training was to get the crews on line and safe ASAP as a/c were arriving frequently. Make an SOP bible that works and management can be confident will not cause too much mayhem, and make violation a hell & brimstone matter. Not great, but it can be argued it works; until the day when the poo hits the airco and thinking outside of the box & comfort zone is necessary. However, in a risk/management environment it can be considered acceptable.
Changing away from this will be extremely difficult and the discussion will go round in circles again & again; as it already has on here.

[dudubrdx]

Well that's funny M.APU: A lot of the TREs in my company seem to think the level of training is very weak, in all countries except their own!! And there are quite a few.
:ugh::ugh:

[doniedarko]

Well that's funny M.APU: A lot of the TREs in my company seem to think the level of training is very weak, in all countries except their own!! And there are quite a few.

...touché...:ok:

[blind pew]

5APUs
250 hours - shear luxury ...the Irish churn the out with 160.....and when I visited Weston there was "icing" forecast so they even stopped circuit training.:ugh:

[roulishollandais]

how do you change an airline's culture and how long does it take?
1980 : I discovered a ATPL exams traffic, with in the shadow a women traffic for blackmails., Some powerful (by family backgrund) DGSE Officer was concerned in protecting de facto the traffics against public interests and air safety.

Mr ARONDEL (AF) was the President of the "Jury des examens du perssonnel navigant professionnel" office..,. GTA and DGAC stopped the enquiry I asked him with plaintiff.

My chief pilot of the moment, (whom I discovered later he also buyed exams) said it was the old "affaire ZIEGLER" .

After ARONDEL came Mr MOUREAUX, Mr GOURGUECHON, aso. FRENCH DGAC NEVER STOPPED THE GUYS WHO BUIED CPL and ATPL EXAMS AND LICENSE and theses guys got quickly airline instructors... You can imagine on which cryteria signatures were given.

Some years ago again I put the thing on the table publicly, and GERARD FELDZER (AF, ACF president, ACF president) confirmed he knew that since in 1980 he was pilot student in the ENAC where the traffic of exams was going too. But nobody worried.

Telling about that on different occasions with French aviation people I often listened the now famous "PILOTS DO NOT NEED TO KNOW THAT" about airmanship and aviation knowledge
(All the persons names are already public)

[jcjeant]

1980 : I discovered a ATPL exams traffic, with in the shadow a women traffic for blackmails., Some powerful (by family backgrund) DGSE Officer was concerned in protecting de facto the traffics against public interests and air safety.
When you know what happens now in the political circles in France .. it's not astonishing ... corruption and fraud are rampant .....

[B888]

Quote: FIREFLYBOB

Psychologists have established (and subjectively I think they are correct) that when humans become "maxed out" the first "sense" which the brain deletes is that of hearing. ie the ear (physically) hears what is being said but the brain says "hey am too busy to listen to that at the moment!".

May answer the question to a number of overruns, but do you have any
Reference Material to back this up?

[BOAC]

No reference material but a fair bit of experience in cockpits when the other person can go 'deaf' when things get difficult. Missed RT, missed inter-cockpit words etc.

[ManaAdaSystem]

I thought the "loss of hearing" was common knowledge?
The very first sense to go out the window when a person gets stressed is the sense of humour. Then the hearing loss follows shortly after.
I don't even have to find documentation for this, it's my personal experience.

[B888]

Quote :

I thought the "loss of hearing" was common knowledge?
The very first sense to go out the window when a person gets stressed is the sense of humour. Then the hearing loss follows shortly after.
I don't even have to find documentation for this, it's my personal experience.

I do agree with you however I may have the opportunity to tell pilots this in the classroom and having reference material will be an asset to back up what is said.

[alf5071h]

Not ‘loss of hearing’ per se, but limited attention resource.
General concepts outlined by James Reason in ‘The Human Contribution’, and most books on human factors.

Also see ‘Lack of Attentional Resource’ page 23 et al, in Monitoring Matters (www.caa.co.uk/docs/33/9323-CAA-Monitoring%20Matters%202nd%20Edition%20April%202013.pdf). A good document, although after this accident and similar, some aspects the philosophy of monitoring might need to be reconsidered – cross monitoring, self-monitoring.
CAP 737 (www.caa.co.uk/docs/33/CAP737.PDF) is another general reference.

[B888]

Thank you alf.
Very useful.

[fireflybob]

Thanks Alf - been looking for the references too - somewhere in my library!

[Ian W]

There is a lot of research on 'Cognitive Overload' (see Wickens’ (2002) Multiple Resource Model). Verbal analysis appears to be a 'single channel' in the human brain. This means that you can read and understand or listen and understand but you cannot do both simultaneously. So someone who is concentrating on reading say the check list - or even visualizing the check list and verbally analyzing the memory - will appear not to hear what is said to them, even STALL STALL STALL. There is a similar issue with spatial analysis so if you are listening to someone on your cell phone while driving and they start giving you directions your brain will start processing the spatial analysis from the phone call - and will stop processing the visual cues from the road you are driving along; this is one of the reasons talking on the phone is dangerous.

More interesting still these cognitive channels also have a level of interference with each other. So if you are attempting to regain straight and level in Alternate law watching the various instruments and trying to listen to the PNF reading checks you will miss a lot of what is being said.

I do not believe that sufficient thought is given to cognitive overloads in the design of instruments and flight deck procedures: add the startle effect and 'automation surprise' plus the sudden stress of an aircraft that appears to be behaving differently to the instruments - and it will appear that the PF is ignoring everyone and auditory cues. This is a human limitation. If you don't believe it recite a nursery rhyme and as you do re-read this posting and have someone talk to you and try to understand what they have said. You cannot do it. The only input that will break into this lock out is 'haptic' that is touch - smack the guy on the arm and that will usually break attention from the other cognitive inputs

[Capn Bloggs]

No reference material but a fair bit of experience in cockpits when the other person can go 'deaf' when things get difficult. Missed RT, missed inter-cockpit words etc.
That's the crux of it. "When things get difficult". Why are things "difficult"? Because we don't do them often enough. I'm not suggesting that we all start doing these yahoo approaches on a regular basis, but sitting there with arms folded watching the machine go along the magenta line is doing absolutely nothing for our ability cope when placed under a bit of pressure, as these guys were (runway change).

We need more "left field" scenarios in the SIM to help us learn how to cope with these "unusual" situations.

[Juan Tugoh]

More left field scenarios that allow us to press on regardless, or give us the belief that we can press on regardless?

The answer to this was always to stop the approach and take a moment to sort out the height problem. That should be the point of training, not to develop techniques to allow the sort of macho attitudes displayed in this incident.

Capacity was the problem here and spending more time in the sim will not increase that significantly, it may help you to realise when your bucket is full and to try to give yourself more time but not if your training department is pushing you into situations whereby it is acceptable to press on.

The brave and macho thing to do would have been to accept that they had messed up and broken off the approach, accepting that we can mess up and owning the error and the consequences of that error are what HF is all about. While we try to develop ways of pressing on rather than accepting we cannot and must do something positive this sort of incident/ accident will continue to happen.

This is a cultural problem - Air France seem to have a problem within their safety culture, this is not their first press-on-itis incident.

[A4]

+1.

I cannot understand why crews cannot see how simple it is to fix :confused:

[alf5071h]

A4, is your difficulty in understanding matched by that of explaining how the problem might be fixed?

There are many aspects to this subject. For example, has the industry identified ‘the problem’ – is it a situation where human input might help with a solution; or it ‘a mess’ – where the human is part of the problem in finding a solution. (A quote from ‘Systems Failure’ (www.demos.co.uk/files/systemfailure2.pdf), a pamphlet on Systems Thinking.)

This subject appears to fall into the category of Wicked Issues, which are associated with complex systems. (Quotes below from Connecting the dots. (www.demos.co.uk/files/Connecting_the_dots_-_web-2.pdf?1259947418))

A wicked Issue:-
The site of persistent failures; repeated attempts at ‘solving’ the problem have had little effect.
The source of profound disagreement – over what the problems are, as well as over the improvements to be made.
Unbounded in scope; the issues sprawl outwards and interconnect with many other problems.
Resistant to completion; wicked issues cannot be ‘solved’ once and for all.
Complex, in the technical sense of being in principle unpredictable.

A best we might only:-
Avoid the worst ‘unintended consequences’
Avoid overestimating what can be achieved
Identify ways to be most effective

“If man is not to do more harm than good … he will have to learn that … where essential complexity … prevails, he cannot acquire the full knowledge which would make mastery of the events possible. He will therefore have to use what knowledge he can achieve, not to shape the results as the craftsman shapes his handiwork, but rather to cultivate a growth by providing the appropriate environment, in the manner in which the gardener does this for his plants”. Von Hayek, ‘The pretence of knowledge’.

[captplaystation]

"Mission" fixation / Pride (sorry to French colleagues , but I think that may be the main player here ) / Perceived "loss of face" / lack of knowledge of true capabilities of aircraft/ lack of situational awareness / task saturation / failure to prioritise realism over blind faith. . . . . well, maybe not an exhaustive list, but that is what we are up against.

Normally one of the 2 should be sufficiently aware of how screwed up it is, and normally he should be able to communicate this in a timely fashion to his colleague. . . . as I used to mention in a previous company where "normally" was a buzzword. . . . "normally" is merely an expectation - rather than the reality, past present or future.

[BOAC]

Alf - that is all terribly grand wording for
"They screwed up and with their experience should have seen the dog's cojones hanging in front of them at 30nm" is it not?.

[alf5071h]

It may be grand wording, but I hope an improvement over many posts which infer understanding via blame, and thus it won’t happen to them, but without actually understanding how or why.
So whilst stating the obvious “… should have seen …”, "… why didn’t they…” can be self-gratifying, it does nothing to improve safety.

In order to avoid these types of incidents and similar events resulting in accidents, the industry has to put aside error, blame, culture, etc, in search of 'cause'; instead perhaps look at what goes right, and question why in order to achieve a better understanding so that individuals and operators can experience more of what goes right.

[A4]

Thanks BOAC - pretty much sums up my take :D:D

Events of this magnitude are rare. Alf, I don't know if you're a pilot or not but we're talking about fundamentals here. It's a bit like an accountant trying to add up a ledger, but putting on a blindfold before operating the calculator - you just wouldn't do it because you know the chance of getting the sums correct are zero. A Professional pilot should have the ability to admit they've screwed up. Hopefully they learn from it and don't do it again.

So there is no "problem" to be identified - other than, IMHO, cultural or attitude - be that macho or nationalistic.

Alf - we were both typing at the same time. Your second point regarding blame culture is valid - to a point. Most developed airlines have active monitoring systems in place so that events like this can be investigated and the crew debriefed and retrained as required. However there is definite difference between an approach which was a bit high/fast and only just made the required "stable gates" and one such as this which was nothing short of reckless. Sometimes you've got so say it like it is - this was screwed up on a mammoth scale and the crew should be managed accordingly. Sometimes sanction AND retraining is warranted. The sanction may well go a long way to enhancing safety culture because it sets a precedent - if it's kept quite then no one benefits.

[alf5071h]

A4, yes ‘a Professional pilot should have the ability to admit they've screwed up’, but more often we don’t do that, even to our self. ‘Hopefully we learn from it’ and strive to avoid similar circumstances.
With the greatest respect to visually impaired accountants who manage their jobs successfully and accurately, I prefer pilots without a blindfold of ‘it won’t happen to me’.

Human performance is variable; this incident can be judged as an (unacceptable) extreme, and although the outcome was safe there was still risk, but at some point that was managed – why, how. The issue is not about the acceptability of risk, but one of human performance where variability is ill determined as too might the level of acceptability – that's in the eyes of the beholder, who draws the line. We all need to draw our own lines, but how can we be sure it is always in the right position.

I agree that the industry should put aside the search for ‘the problem’; “…accept and accommodate ambiguity over what the problems are, ‘defining the problem’ need not , and, often, should not, be the starting point …”
We should heed the principles of human factors, of systems thinking, and of how safety might be improved - the fundamentals.
We should accept that this type of event can be seen from a different viewpoints, not exclusively of being ‘reckless’ or ‘they should have done better’, but with views attempting to understand how this, the next crew, or ourselves might avoid such circumstances.

How can the industry avoid or overcome those issues identified by cps (#102), and identify which items come together ‘by chance’, or be of significance in particular circumstances.
There are many pilots operating today who can and do accomplish that, but are they able to explain how or why, or provide assurance their performance will always be adequate.

[737Jock]

At FL207, 33nm to touch down, 276 KIAS the captain selected the autopilot into open descent, reduced the thrust to idle, deployed the speed brakes and selected a speed of 300 knots. The aircraft reached a rate of descent of about 5000 feet per minute and descended through FL120 about 20nm before touch down, the captain selected 240 KIAS which also reduced the rate of descent. The aircraft descended through FL100 13.5nm before touchdown, the autopilot was disconnected, the landing gear was selected down, the crew reported runway in sight. Doing 250 KIAS the aircraft intercepted the localizer 8nm before touchdown at 6000 feet, 3400 feet above 3 degrees glideslope, the captain selected the go-around altitude into the flight control panel which caused the flight director to revert to vertical speed (4400 fpm rate of descent). Descending through 3550 feet, 1700 feet above glide, about 5nm from touchdown, flaps still at position 0, vertical speed -4400 fpm, speed brakes and landing gear extended, the first officer (ATPL, 1,700 hours on type) transmitted they were established on the ILS 19. The autothrust was disconnected, the engines were reduced to idle thrust. The aircraft received landing clearance. 8 seconds after the landing clearance the first officer advised they were "a little high" and requested a 360 (full circle) to the right. During these communications the captain re-engaged autothrust and autopilot, the glideslope capture activates, a GPWS warning "Sink Rate!" sounds at 836 feet AGL, 220 KIAS, 2500 fpm rate of descent 2.5nm before the runway threshold. The GPWS calls "Pull Up! Pull Up!" and "Too low! Terrain!"

This is more than a screwup, this captain clearly doesn't know his aircraft nor what it is capable of.
To start of by accelerating to 300kts and then slow down to 240 kts at a point where you haven't even captured the profile is an enormous beginners mistake. You either speed up and stick with it until your below the profile, loosing the speed at lower altitude in denser air with every bit of drag there is, or you slow down straight away and put the drag out.
When you are this close and this high the only option that could lead to possible success is to slow down and get the drag out. With FULL and gear at 160-170 kts the airbus can give quite an impressive rate of descent at lower speed which buys time and thus improves the angle of descent. And at least it's fully configured. Still don't think it would work but in my opinion it's the only strategy that could have been attempted.

He then seems to manage to get the engines running above idle in v/s with speed brakes and gear out, at every step he is adding to his problems.

Anybody can make a mistake and get high, this guy doesn't know how to operate his aircraft though and is too arrogant to ask for some 360's or extra vectors.
The weather being good has little to do with it, weather doesn't change the laws of physic nor distance to the threshold. In fact when I can see the runway rushing towards me while I look way to high it's extra confirmation that something is going wrong! It's not a motivator to push on.

[Right Way Up]

Alf,

‘Hopefully we learn from it’

And here is the rub, somebody has got a bloody big alarm bell and rung it in the ears of the Air France community, and they are still not getting it! :rolleyes:

[BOAC]

Not just 'a bell' either, RWU - more like a Westminster Abbey session - are they going to admit the problems?

For all the reams or words that psychologists will write about this and other recent events, there comes a time when one has to say let's not give all these events grand names and analysis - they are 'cock-ups', plain and simple, and I have yet to hear of any course one can introduce to stop those, and in many ways by introducing the 'psychology' approach one is almost admitting the problem is pretty wide-spread, instead of a few mavericks.. Cut out the rot is the best way. 'Hang 'em high' is sometimes the best solution.

I suppose looking on the bright side a pilotless aircraft would have flown an orbit..............:ouch:

[Capn Bloggs]

they are 'cock-ups', plain and simple, and I have yet to hear of any course one can introduce to stop those
I have. It's called training and education.

[BOAC]

I wish to invest in your company Capn - anyone who can eradicate human stupidity through 'training and education' is set to make a mint!

[RAT 5]

This, and the Thessaloniki incident, are all taking about the captain did this to screw up he kept digging etc. In TSL the operator might have a cockpit gradient and culture problem. This has been mentioned for years and the MCC CRM courses in western airlines are supposed to have levelled one and eradicated the other. Yet this is AF; a major ancient player.
In both cases a perfectly sensible (hopefully), educated, qualified, intelligent individual = F/O sat and watched while some other clown tried to kill him, yet did not a lot to help his survival. That leads to 2 questions. How did the clown get to be in LHS in the first place and then dig this hole? And why did the F/O stare death in the face so meekly?

[BOAC]

Maybe there is a huge 'gradient' in AF? Look at the farting around in 447 where no-one seemed to be prepared to say boo to l'oie until le chef arrived.

[deptrai]

Thanks Ian W for pointing me to " Multiple resources and performance prediction" (Wickens, 2002) http://sunburst.usd.edu/~schieber/psyc792/workload/Wickens2002b.pdf

some heavy reading...jumping to the conclusion:

"Basic psychology and neurophysiology must identify the characteristics of human information processing that make such endeavours more, or less, successful. The analysis and prediction of human productivity and safety in high workload environments requires models to predict such di€fferences."

In summary, scientists are starting to understand more about "cognitive overload", and there are some interesting theories, yet - more research is needed.

[Natstrackalpha]

He thought he could make it but he couldn`t.

[alf5071h]

BOAC, “… one is almost admitting the problem is pretty wide-spread, instead of a few mavericks …”
Yes, ‘it’ is widespread. It is called human behaviour and, even after selection, training, and education, it varies across the complete spectrum of operations.
You wish to draw a line to delineate the norm from the maverick; by all means do so, but please specify where the line is to be drawn for every situation which a pilot might encounter, to enable us to avoid these situations.
I choose not to draw a line, instead seek those factors which contribute to variable human behaviour, and then how these could be improved to achieve a more consistent and hopefully less variable human performance.


RAT 5, Assuming that the PF misjudged the situation (variable human performance), then for other than probability, what would indicate that the PM understood the situation any better than PF, and thus could have chosen to intervene.
Both pilots were in the same situation, thus their perception and understanding could have been similar, as we expect in everyday normal operations. But without evidence we cannot tell – probabilities or otherwise.
To some extent cross monitoring depends on detecting a difference in understandings, but if the mind-sets are similar then there may be no disparity to detect – again as in normal ‘safe’ operations.

There is opportunity for self-monitoring as a defence – “how’s my thinking”, “what does this mean”, but this too can suffer from ‘dual’ failures, and there may be other disparities between pilots due to training and experience.
An analogy is like suffering spatial disorientation, where both pilots can be similarly affected; except in this instance it might have involved cognitive disorientation – overload, which demands intentional resource. Whereas with the less attention-demanding spatial disorientation, we might be able to recall the mental drill of ignore our senses and believe the instruments.

[tubby linton]

I thought most airlines had gates to meet on the approach. If you don't meet the gate then you do not proceed to the next phase and must do something to achieve that gate before you can proceed. The first gate would be 250kt at 9000ft at 30 nm.Airbus publish this in the fcom but in this case the flight was so far away from it that it beggars belief that they continued. If you are trying that hard to make an approach work then it probably will not work and you should only persevere if the aircraft is on fire.
I have noticed a certain misplaced arrogance from observing AF operations over the radio over the years and I would not fly with them by choice.What is more disturbing is that their head of safety who oversaw a numer of hull losses is now a big wheel in EASA.

[A4]

With all due respect Alf, you have a way of using some "big" words trying to almost "justify" this crews actions. As I said a couple of posts back, this was an "off the scale event" which needs, to put it bluntly, a severe reality check/correction for the individuals involved.

You ask "where the line is drawn"? Well, if you've programmed the FMGC correctly, put the descent winds in and the constraints you require/want in the descent, the aircraft will draw them for you! And it TELLS YOU it "ain't gonna work"......

BASIC training when you come onto jets is, typically, 3 x your height + 10nm to slow down for a "normalish" profile - these guys didn't even get close and no amount of what / where / why / how / fluffy can start to "soften" what they did.

The more I've thought about it the more "angry" I feel about it. It could be argued that these guys are the equivalent of the market traders who "bet the farm" in the hope it would come good but didn't and lose £x hundred million. The difference is that these characters had the potential to take 150+ soles to meet their maker.

It can be analysed to death - they screwed up and didn't sort it early - bottom line.

You talk of "dual failure" of cognitive overload. Overload, typically, only occurs in the latter stages. If you're 20,000' at 30d there is NO overload at that point. Any pilot with any NORMAL, EXPECTED "cognitive recognition" would say AT THIS POINT, "we need more track miles" - stress, risk, error, high workload - REMOVED.

Sorry to sound blunt - this was a totally unnecessary event. Macho BS/pride - call it what you like - no amount of psychobabble will ever justify this to me.

[rottenray]

The more I've thought about it the more "angry" I feel about it. It could be argued that these guys are the equivalent of the market traders who "bet the farm" in the hope it would come good but didn't and lose £x hundred million. The difference is that these characters had the potential to take 150+ soles to meet their maker.

Thanks, A4, for an injection of reason.

The "punters" sitting in A thru whatever ARE NOT paying for someone to "hope" it will all come out right.

Teh simple :mad: who financed the airframe's purchase didn't to so with the intent that someone piloting the multi-million $/L aircraft would reach a point - in routine operation - "hoping" it would all work out fine.

And lastly, AF certainly didn't (and prolly doesn't routinely) put people in the LH seat who can only hope a routine approach and landing will come out okay.

First order of business - heads on spikes.

Next, sort out the culture which caused this to happen, and make it public so everyone can learn.

[CDRW]

Rottenray - well said and totally agree with your post

[bubbers44]

AF447 and this flight show a lot of problems with some airlines needing more aggresive and competent junior pilots to not let the pilot flying put the flight into jeopardy through poor decision making and aircraft management.

It wasn't a problem during my career because our airline hired captains with experience and confidence in handling situations as FO's. We didn't let things get out of our comfort zone like we see some new pilots doing today with low experience. Unfortunately you get what you pay for.

[fab777]

Guys...

What do we have here?

A one-year old incident, with a grossly unstabilizes approach and go-around 100 feet below the gate, crew intervied and managed, report issued and transmetted to the authorithy and the AF pilot community, corrective actions taken.

On the other hand, 7 pages of one-year behind schedule internet flame fest of what I understand as "AF pilots ( read : french ) have a cultural problem ( read: don't know how to fly )"

I do not deny there was some work to be done within the airline ( work beîg done, believe me ), but it smells a bit like french-bashing here...

[737Jock]

Has Nothing to do with french bashing... AFbashing maybe, but with cause! There seems to be a new one-year old report every 3 months or so. Other european airlines including KLM and the lowcost airlines (which AF crews like to bash on the frequency) perform a lot better!

I really have zero respect for this cockup, sure we all get high and nobody really likes to ask for extra trackmiles (I do it, but I don't like it if it is a result of my actions, I don't like speedbrake either but use it if needed).
But when ATC swapped the runway, they gave this crew the perfect excuse to request extra trackmiles without denting their precious ego's!

And yes AF has to many rotten apples anongst their crews with ego's that are too big! That is based on their comments in French about other airlines which they believe don't understand their insults/slang and general whining!
Other French airlines don't act like this, not do French pilots in lowcost companies.

[A4]

It's not French bashing. The B738 over-run at Thesaloniki thread has similar views being stated but that crew were not French (as far as we know).

What cannot be denied though is that AF appear to have had more instances when things have gone way outside the envelope of normal operation. Some they got away with, some they didn't :(

A340 overrun landing during a TS in Toronto. Hull loss, miraculously all survived.

A330 - AF 447 incorrect reaction to unreliable speed and subsequent stall. All lost.

A319? - go-around at LFPG mishandled by Capt resulting in aircraft "porpoising" down the runway at very low RA - 76' with gear UP!

A340 - approach into LFPG earlier this year(?) with similar characteristics to the one this thread is about i.e 9d@10,000', 4d@3,700'.....and subsequent 26 degrees pitch and low speed after false glide capture :eek::eek:

A320 - AlphaFloor activation during visual approach into MRS.

These are factual incidents. There's probably more but I can't remember them. All airlines have their moments when things go a little awry be it ATC, weather or self induced. This is not French bashing - it's just stating a fact - and we're only discussing 1 year after the event because its only just come to light.

You say that work is being done within AF - well that's great news - let's all hope it has the desired affect and prevents a repeat of the above incidents :ok:

[RAT 5]

Assuming that the PF misjudged the situation (variable human performance), then for other than probability, what would indicate that the PM understood the situation any better than PF, and thus could have chosen to intervene.
Both pilots were in the same situation, thus their perception and understanding could have been similar, as we expect in everyday normal operations. But without evidence we cannot tell – probabilities or otherwise.

This statement, from your HF references, could, by your theory, also be applied to the TSL incident. However, at TSL they were visual and PM sat and watched, passively, for many minutes, as the captain was trying to kill them all. It was not a THY AMS surprise scenario. It was not even an AF CRZ stall with a 'what's it doing now?' conundrum. From the video it seemed like a nice long straight in visual finals. A G/A can still be made at any height, even from on the RWY up until TR's are deployed. As they floated down the rwy searching for the ground with too little flap and too high a speed, it was perfectly obvious to PM that this was not a good place to be. The hole was deep and getting deeper. After all the world incidents/accidents of this nature that have been spread around the aviation industry why are PM's still allowing this to happen? If the F/O had been PF would the captain have sat back, dumb? Jeez I hope not; but then it was the same clown who put them in this hole in the first place.
Same with AF. If PM could not perceive that they were getting into a deep hole that was getting deeper they shouldn't be at the sharp end. PF might get mentally fixated on the mission and tunnel vision. I doubt there was much explanation from PF about what he was doing and how he was thinking it was going to work out. I suspect he was fixated and moving hands and eyes rapidly searching for the golden key. PM should have been thinking his own thoughts and feeling very nervous for his own survival. I don't get it that he might also have been unaware that things were going wrong. His brain was on a different channel to PF and receiving different inputs and making different calculations: I hope.

[Pinkman]

I'd be interested in the extent to which regulars think that the BA pioneered QAR system, with post flight analysis (I've seen the system and found it mind blowing) has been responsible for changing culture and attitudes, and weeding out persistent flight envelope busters.

Although AF have the QAR I notice in the Tunis report they refer to it as a "maintenance recorder".

Does that mean they only use it for maintenance related purposes or do they have a program, like BA, of flight envelope data sampling, analysis and confidential reporting of parameters when exceeded? If not, would the unions permit it?

[alf5071h]

A4,(#118) Not attempting to justify, but trying to understand, and to learn.
No psychobabble, just a humble pilot who during a long and varied career had opportunity and interest to ask why; primarily about self.

IMHO I see ‘anger and bluntness’ as issues of hindsight. “Any pilot with any NORMAL, EXPECTED "cognitive recognition" would …”, is an assumption, because it is difficult to establish what demands were placed on the incident crew at any stage of the approach. It was their view of the situation which gave them a unique (and possibly flawed) understanding; and like all experiences these cannot be relived exactly or simulated. It is similarly difficult to define a ‘normal’ pilot, let alone their cognition as a measure for everyone; thus what is the scale by which to judge others, and again what is on/off limit.

Everyone’s view is important as they bring different understandings to incidents and the safety of our industry, but we must separate biases such as hindsight, explanation before understanding, cherry picking events, or ill-defined statistics from ‘fact’ and understanding, however strongly we might feel.

In this incident the crew ultimately went around; why. Whatever ‘view’ that ‘caused’ the pilots to change their intent – a process, was probably similar (but probably a converse view) to that which got them into the situation in the first place.
We should ‘celebrate’ the success of the GA (in a very small way), understand why, and from that identify what we might learn.
Isn’t that the point of Ut Sementem Feeceris ?

[BOAC]

Alf - I will preface this by saying I know you have had 'a long and varied career', which I readily accept and respect but I fear you have now been 'seduced' by what is known here as psychobabble.

""Any pilot with any NORMAL, EXPECTED "cognitive recognition" would …”, is an assumption," I suspect 99% of pilots, certainly A4 and I, would say it is a fact.

"difficult to establish what demands were placed on the incident crew at any stage of the approach." as A4 said, the only 'demand' at runway change was a challenging vertical profile, not enough to cause mental panic, and when they realised they had been in V/S it would have been READILY apparent that more track miles were needed. No question. So I see no demands that could not be readily handled.

"It is similarly difficult to define a ‘normal’ pilot, let alone their cognition as a measure for everyone; thus what is the scale by which to judge others, and again what is on/off limit." in this case not - see reference to 99%

"In this incident the crew ultimately went around; why." do we need to ask? Does that need 'analysis' too?

"Whatever ‘view’ that ‘caused’ the pilots to change their intent – a process, was probably similar....." ???? Probably the 'view' out of the window showing no runway to land on? Let's not get TOO carried away with 'the mental processes'.

"We should ‘celebrate’ the success of the GA (in a very small way)" well, yes, in a very big way, actually, a small straw to clutch at and one that no doubt 150 odd pax and crew, not to mention family, friends and Air France, appreciate too.

As far as "Ut Sementem Feeceris" is concerned, the best thing to do is not to sow the seed in the first place, which is, I believe, what Captains, like you and I were, are paid to do in the trust that they are "pilots with any NORMAL, EXPECTED "cognitive recognition ." Cogita ante salis or Caveat emptor seem appropriate?

[RAT 5]

In this incident the crew ultimately went around; why. Whatever ‘view’ that ‘caused’ the pilots to change their intent

Crew = more than 1 pilot, and the pilots confirm who you are discussing. I would suggest that only 1 pilot = PF was involved in executing this scenario. Was the G/A initiated by PF or did PM at last wake up? I don't know, but I have a strong gut feeling that the start and end of this semi-suicidal escapade was not a 'crew' matter. I very much doubt if PF turned to PM to enquire of his opinion if the subsequent approach might be executed successfully & safely. I suspect PF plunged the a/c towards the rwy and PM was trying desperately to catch up with what was confronting him and hanging on. I hope it was PF who finally decided to bail out of this imminent train smash, and the relief on PM's face improved the smell in the cockpit.
I would be ver curious what the F/O said after the engines were shut down. I've missed if they flew back together and what the atmosphere must have been like. I wonder the same questions of the TSL incident. There have been many other averted disasters where the F/O had a chance to say his piece, but I wonder if they ever did. There is one story I know of where the captain on a severe clear day executed a high energy visual and ended up with a glide landing at F5/10. Flap limits had been exceeded. No entry in the tech log etc. etc. No engineering inspection, even though they were available. Yet the F/O stayed on board and flew back with the clown, probably very silently. It was automated data retrieval data that blew the whistle a few days later. Amazing. The question people often ask is 'what would you do to force the G/A?' I can understand that; let's try and learn; but to say nothing to management about your concerns of the captaincy/piloting skills of an employee who might then go out the next day and do the same only worse; that I find also lacking in judgement. If we're dealing with HF matters in the build up to the incident, I think we can also consider the HF matters afterwards and ask why the silence. I know it is easy to ask and very difficult to blow the whistle, but just give it some thought if it happened to you and your wife & kids were booked on his a/c the next day.

[bubbers44]

I didn't mean to bash anybody but an FO's job is to make sure the flight is conducted safely and to intervene if necessary. I have done it on very rare occasions because it is my responsibility, not my loyalty to my captain or whoever is PF. I guess when I took over a 4 engine jet from my chief pilot and went around with him trying to land long on a wet short runway with no chance of stopping is when I realized having a job is not as important as doing your job as a pilot. I thought I was fired but he thanked me for what I did. Never let your flight you are responsible for as a crew member be compromised by letting another crewmember put it in jeopardy.

[roulishollandais]

A philosophy that prone SOP absolutism is even worse than a despotic Captain that is wrong. It locks absolutely the other crew members. This is true everywhere in the world. Europe is looser and so absolutist as counterpart. Freedom is not a luxury but a vital necessity. Bubbers44 your freedom vs SOP did your decision lucky.I realized having a job is not as important as doing your job as a pilot. I thought I was fired

[Checkboard]

An airline flight is all planned and conducted on the underlying assumption that it will go ahead and fly to completion.

One person is designated as Commander, and that Commander has one responsibility -

That is to say "no", when everyone else is saying/assuming "yes". :hmm:

[B-HKD]

Suggest thread title change to "Air France does a Air France" :E

[alf5071h]

BOAC, you provide important views of these issues (#128).
Seduced by psychology? I hope not; just one of many alternative views that I strive to understand.

Your post reflects many others in this thread, with the apparent inability to define ‘facts’ such as normal or expectation. Also note the lack of explanation as to how pilots might avoid these unwarranted situations; but that everyone else can*; e.g. “I would have known”, “it’s obvious”, “would be readily apparent”, “do we need to ask” – not just your words.
The words (feelings) indicate aspects of knowledge and particularly the application of knowledge. These identify with ‘tacit knowledge’ (http://en.wikipedia.org/wiki/Tacit_knowledge). In aviation this is often described or included within experience, airmanship, or professionalism.

Thus we all know what should be done or what not to do, but have difficulty in explaining it. This suggests problems in training, but we should not overlook cognition; “the idea that certain cognitive processes and/or behaviors are inaccessible to consciousness.” – see web links.

The words associated with tacit knowledge might provide further insight. Note that these aspects also appear in the thread, often veiled under ‘the individual’, ‘nation’, ‘organization’, or ‘culture’:-
Perceptions, ideals, values, emotions and mental models so ingrained in us that we take them for granted.
Individual experience, intangible factors, personal beliefs, perspective, subjective insights, intuitions, and hunches.
Though they cannot be articulated very easily, this dimension of tacit knowledge shapes the way we perceive the world around us.

Earlier I recalled being taught 'airmanship' but knowing how; this is typical of tacit knowledge. Thus we might consider what form of training enables the necessary understanding and if that still applies today.
Does the industry have an ‘apprenticeship’ scheme; do experienced pilots mentor junior ones, do we always brief / debrief, or question ourselves. How long does it take to become experienced; is there time.

“Effective transfer of tacit knowledge generally requires extensive personal contact, regular interaction and trust. This kind of knowledge can only be revealed through practice in a particular context and transmitted through social networks. To some extent it is "captured" when the knowledge holder joins a network or a community of practice.”

IMHO the issues underlying this type of incident are in these areas; modern operational scenarios are more resource demanding, require greater awareness, there are more limits and procedures, less time both in the air and on the ground.
Problems thrive on change, thus we could focus more on what has changed, particular the gradual aspects, which we might not have noticed or fully understood the consequences.

Knowledge (http://www.nwlink.com/~donclark/knowledge/knowledge.html)
http://proceedings.informingscience.org/InSITE2004/050maqso.pdf

* I exclude the tools such as rules of thumb, gates, alt/distance tables, assuming that there are known, and focus on the mental process which enables their use.

[SR71]

My own experience from a dark and stormy night going onto 06L in PMI is that it is quite possible to get in off an approach with (2 x Height) in Track Miles to run.

In this particular situation we predicted the event as a result of multiple TS's in the vicinity with some nasty returns delaying our descent, briefed the cabin on the eventuality so they were all secure before we reached the intermediate descent stage, and deployed the gear at limit speed minus a few knots from FL160, fully cognisant of the fact we might have to throw the approach away if we were unable to satisfactorily manage the energy equation.

I honestly don't remember it as that much of a deal except that we were at FL160 with ~30 miles to run. I fully accept this isn't a "normal" approach and is probably pretty uncomfortable for passengers, but it wasn't your normal night in PMI.

The headwind component will have a significant effect on the outcome but I can't remember what it was....

[captplaystation]

A humble 737 (well maybe NOT a 738WSFP. .that is a bitch ! ) can easily do the equivalent of 6 degree approach I.E 10 miles 6000', but. . that is assuming you drop the gear & all the flap right through to 40 at the limit & then fly at the limit for F40-5KTS (either manually or automatically if you can REALLY use that MCP . . & so few can regretably ) till the 1000' or 500' gate. Done it a few times due either my own, or ATC's misjudgement, but always with a defined moment to say "game over", and always keeping my colleague in the loop.

These AF Jokers were so far out of these parameters that they were not operating to any pre-rehearsed "recovery scenario". . they were just hoping that Physics were somehow having a "left-field" day.

[A4]

Yes SR - but you BRIEFED (including the CC), PLANNED, MONITORED,were ENERGY AWARE and accepted you may have to throw it away. BIG difference. You didn't continue to < 500' with the GPWS shouting!

Alf - I can see what you're getting at BUT this was not an inexperienced crew (Capt 10,000TT with 2,600 on type, FO 1,700 on type). The FO should be past the mentoring stage and the Capt....well.....I'd like to think he should be all "tacit'd up" by now!

.....modern operational scenarios are more resource demanding, require greater awareness, ......


The Airbus PFD, ND, FMGC PROG Page are very useful Resourses and are there to enhance awareness. We are spoiled today with the sheer quantity and quality of the information presented by a modern airliner FMS - but you've still got to be able to do the basic mental maths to back it all up. IMHO this crew didn't.

Whatever the reasons - be it arrogance, inability, culture, cognitive overload, weak FO, dominant Captain, fatigue, (lack of) Training - there was a near lethal cocktail on the flight deck that day and they only just got away with it.

[rottenray]

but always with a defined moment to say "game over", and always keeping my colleague in the loopAnd that is the the big issue.

What's wrong with the culture when 2 men who are responsible for hundreds of lives cannot - or will not - err on the side of caution.

Courage is where you find it, and you won't usually find an opportunity to be courageous by taking the riskiest action.

Usually, courage is quiet and is the result of applying one's knowledge in an unexpected way.

[bubbers44]

The captain should always make the decisions and the FO should always as 2nd in command support him unless he can't because it puts the flight in jeopardy, then it is his job as a crew member to protect his crew and passengers to do what ever is neccesary to protect them. Never let another crew member put your flight in jeopardy. I don't care what country you live in. This is a pilot's responsibility to his crew and passengers, not to his airline.

[AlphaZuluRomeo]

but always with a defined moment to say "game over", and always keeping my colleague in the loop And that is the the big issue.
Agreed.
That are the conclusions of the report, too :)

[gazumped]

Bubbers makes a very good point, he intervened to prevent his chief pilot from continueing an unstable approach ..... well done.

I wonder what the mental resistance to intervene actually was.

This resistance, almost always unsaid, is highly dangerous. For example the captain as PM would intervene at a fairly early stage, given similar circumstances. Why is that so? Let me answer my own question, captains intervene if they are unhappy with profile ( or other issue) because they are used to dispensing authority, they are practiced at giving orders and they expect compliance.
The First Officer usually is not so equipped.

80% of hull losses involve the captain as PF, and making a tactical error (or series of errors) , and critically, the FO fails to effectively "speak up".

I have a little routine I employ on the first sector. I share the above statistics with my FO, and I inform him that he is the most important safety feature of my aircraft. I then tell him, nay actively encourage him to speak up, to not be the slightest bit hesitant to point out my errors and oversights. Because I will make errors and oversights, because I am human.
I will guarantee you if I ever have a complete brain fart and attempt to get in from a ridiculously stupid high and hot approach, my FO will speak up!

How do you speak up to a captain who is fixated on getting in regardless?

Our company had an over-run many years ago, 178 kts flap load relief valve doing its job, landing flap still not selected, check list not done, 2 dots high, and all this at 400'. Gues what the FO actually said? "........ You're a bit hot are you happy to continue....? Gues what he captain did? Yep you guessed it..... he continued.

Let me suggest what the FO should have said?.........." You're too hot (or high, or check list not done, or ........ Some such thing).....I THINK YOU SHOULD GO AROUND! DON'T YOU?....." Basically, whatever you suggest to an overloaded fixated crew member, he will most likely do!

That's how Bubbers did it. He gave his captain a solution to the problem........" It's not going to work.... Go around" simple really isn't it?

No psychobabble, just give the poor guy an option, and have the courage to speak up. After all the PF, does not see nearly as much of the situation as the PM does.

[fireflybob]

Agree with all the comments about FO advocating position and (if necessary) initiating a Go Around.

Notwithstanding that as human we can all "screw up" the best fix is to ensure that anyone who gets into the LHS is totally competent in that role.

One aspect is he/she must have an intimate knowledge of the aircraft performance. My observation is that some pilots don't seem to understand that if you are high "close in" the only way you stand a fighting chance of making the approach gates is to slow up and configure, if necessary, all the way through to full (in this case 40 degrees) flap. This seems to be an area which is rarely taught and practised these days.

[roulishollandais]

The first officers real role ?
FO's role or TEAM work ?
French"elites" have a real problem with autority : decreed, often undeserved and poor team work after the flight, in administration, in management, etc..

@ alf5071h
Thank you for the references

[ATC Watcher]

Regarding cultures , or better said, cultural background :
Fact is that the "latin " approach to Team work is totally different than . say the Asian one, jut to take an example. CRM principles were initially designed by and for anglo-saxons , where respect for authority is average but adherence to rules strong. It does not fit all cultures unfortunately, and as we know changing a culture is not easy. Changing a latin culture into an ango saxon one has been tried before. Results were mixed to say the least.

I fly regularly in jump seats with a large airline whose policy is : if any crew member say " Go around" the PF must ( and will) go around first , and ask (or debate) why afterwards.
This simple rule seem to be difficult to transpose into other airlines whose main culture is totally different . I am not sure what is the current AF policy in that matter, and if it had changed after the Brest CL60 crash. (2003) Before that F/O were to " suggest" actions to Capt. I believe.

[bubbers44]

gazumped, in my case with my chief pilot I pushed the thrust levers to go around thrust so continuing the botched landing attempt was no longer an option. Sometimes words alone can't fix the problem. Most of the times, in my experience, if time permits talking works to fix a bad situation but sometimes there is not enough time so more aggressive action must be taken to protect your crew and passengers. If you have to do this more than twice in a career of flying then you have to decide why was it necessary if both crew members were fully qualified and not doing training.

[tom775257]

It is worth remembering that if you tell the other person to go around, there is a chance that they are so out of the loop the go around will not proceed as it should.

This happened to me upon telling a captain to go around, who then proceeded to select MCT and yank the nose up, still in g/s *, loc *, I called 'TOGA,' he selected TOGA, now with correct modes but also now approaching and about to bust missed approach alt, full nose down input with TOGA thrust, flap overspeed almost straight away. I took control then, too late in retrospect.

[RAT 5]

One aspect is he/she must have an intimate knowledge of the aircraft performance. My observation is that some pilots don't seem to understand that if you are high "close in" the only way you stand a fighting chance of making the approach gates is to slow up and configure, if necessary, all the way through to full (in this case 40 degrees) flap. This seems to be an area which is rarely taught and practised these days.

This discussion is not quite in touch with the focus of the thread, but.... I was shown this in anger on B732. It still works as I put it to good use in the good old days of Spanish surprise ATC on B733; much to the F/O's amazement & education. The comment I take issue with is "This seems to be an area which is rarely taught and practised these days."I came across it by force of circumstance in my apprentice years. The attitude now is DO NOT get yourself into a position where you need to use it. Thus demo/training/practice do not apply. It is an escape manoeuvre and not one to be taught except in sim. Perhaps you can explain the philosophy and hope it is remembered when required. Sadly, teaching the a/c envelope is not the modern philosophy/training technique. Re-lighting an old chestnut there are airlines that discourage visual approaches. Sad days ahead. Good days long gone.

[bubbers44]

Pushing thrust leavers to go around thrust takes all of the question of what we are going to do next out of the question. Just do it and deal with what happens next later.

[safetypee]

For a range of views, issues, problems, etc, about ‘Go Around’, see Go Around Safety Forum. (www.skybrary.aero/index.php/Portal:Go-Around_Safety_Forum_Presentations)

[PAX_Britannica]

in my case with my chief pilot I pushed the thrust levers to go around thrust so continuing the botched landing attempt was no longer an option. Sometimes words alone can't fix the problem.

80% of hull losses involve the captain as PF, and making a tactical error (or series of errors) , and critically, the FO fails to effectively "speak up".

I have a little routine I employ on the first sector. I share the above statistics with my FO, and I inform him that he is the most important safety feature of my aircraft. I then tell him, nay actively encourage him to speak up, to not be the slightest bit hesitant to point out my errors and oversights. Because I will make errors and oversights, because I am human.
I will guarantee you if I ever have a complete brain fart and attempt to get in from a ridiculously stupid high and hot approach, my FO will speak up!

How do you speak up to a captain who is fixated on getting in regardless?

Is this taught in sim ? There seem to be training folk round here.
It seems like a classic sim lesson.
Captain (15k hours on type) is landing because the FO doesn't have enough hours.
Captain's behaviour is generally exemplary. But today he's having a brain fart.

[One Outsider]

I think the safe bet is to ignore the input from people like Bubbers44, also known as always knows best. People sure of their own infallibility and excellence usually have a poor understanding of their situation or surroundings.

[PAX_Britannica]

I think the safe bet is to ignore the input from people like Bubbers44, also known as always knows best. People sure of their own infallibility and excellence usually have a poor understanding of their situation or surroundings.
I think the question remains valid regardless of Bubbers44's overestimation - or conceivably underestimation - of his abilities.

I thought the point of his comment was that calmly and quietly saying "Go Around! Go Around! Go Around Now!" might not always be sufficient if the PF's overload or fixation is causing deafness.

[One Outsider]

Anyone can eliminate choices by such moves as advancing throttles and destabilizing an approach. The real question is weather is was a prudent move or not. When one's posting history is mostly about polishing one's own halo the motives become questionable.

[Prober]

Bubbers44 might be a ‘know all’, but that does not mean that one should ignore his posts. I once saved an aircraft full of people – and I am hardly a ‘know all’. I joined a fairly big airline from the military and went from a position of command to No. Zero. I was 3rd pilot on a night flight. I had flown with the captain before and found him very affable and that night he was training another captain to be a training captain. On that particular aircraft there was almost a book of pre-take off checks and, as we approached the runway with no likelihood of holding, I started the check list. I was sharply told to ‘speak when you are spoken to and NOT before’. The flight continued in this vein until, during the procedural letdown, the captain surreptitiously pointed out to me that the ‘student’ was displaying VOR and not ILS. So, we were both aware. The approach continued but the lights of the city disappeared (on a clear night) and I began to get one of those muscle clenching feelings. I leant forward and switched on the landing lights (pre-10,000ft days). As the lights swung into position, they illuminated a farm house just below us. I could see the wireless aerial with one of those old fashioned porcelain insulators holding it up like a washing line – we were that close. I shouted ‘Climb, climb, for f…’s sake climb!’ He did, and soon the lights of the city came back into view.
After landing, when the dispatcher came into the flight deck, he realized that there was at atmosphere and he quickly withdrew. It took about 5 minutes of extreme discomfort all round before the ‘student’ said that he had made a right …. Whatsit … of himself and asked for MY forgiveness. We became friends thereafter.
All it needed was for someone to SPEAK UP!
:ooh:

[One Outsider]

Sure, Proper, there will always be moments when speaking up is appropriate. But when all you have to contribute is when you saved the day and how you save the day, it becomes a bit tedious and contrived. I've lost count of the times he saved the day flying into Tegucigalpa And just to expand on my indignation, the amount of no-nothing, retired pipe-salesmen and whatnot's adding their 2 pence-worth-nothing to any subject around here, really get's up my nose. And I am sure I am not the only one feeling the same way. The amount of completely useless opinions that completely useless people absolutely wants to share here is just mind blowing.

[Capn Bloggs]

If you don't like it, Outsider, leave.

Bubbers can get a little carried away with the warries but most of his stuff is very good. If there were more of him in the seats the industry would be a lot better off, safety-wise.

[safetypee]

OO #151, :ok:

If the industry is going to maintain safety by avoiding similar incidents, then it’s not knowing ‘what’ has to be done or even ‘having done it’. The key points are knowing ‘why and when’ a course of action should be changed, based on an understanding of the developing situation.
This is tacit knowledge; it’s difficult to explain and communicate, but of vital importance – situation awareness, decision making.
Thus those who might know, have done it, or ‘really’ have it, might try to explain ‘why and when’ to the rest of us fallible humans.

[PAX_Britannica]

While folks seem to have more to say about my Bubbers44 quote, I thought Gazumped's quote was more interesting.

Bubbers44 seems to have a high opinion of himself. But here, I don't see that it matters if Bubbers44's anecdote is entirely fictitious, and Bubbers44 is, in fact, a Siamese Cat with an overactive imagination and overdeveloped keyboard skills. Bubbers44's anecdote illustrated what Gazumped was attempting to train his FO to do.

Gazumped appears to be attempting to train his FO. A part of this may be to break the ice, and make it clear to the FO that [s]he is not merely PAX in a front seat. Perhaps Gazumped seems concerned that corporate training may have been not been entirely adequate. Gazumped should be flying in an Airline where he is confident that he does not need to do this.

[Machinbird]

1. I personally like Bubbers, and I think I understand where he is coming from. With probably 20,000+ hours of varied flying, he sees things about the direction that modern aviation is going regarding loss of aircraft handling skills, and that probably gives him heartburn. Now that he is no longer in the pointy end of things, able to influence other pilots in a one on one basis, all he has left is the ability to reach out and pass on his hard won lessons to those who will listen.

2. Bubbers lesson in how to "save" a bad approach of the person flying by forcing the go around shows personal courage and readiness to act when things begin to go pear shaped. I would be willing to bet that the decision to over-ride was made by him months or years before and was waiting for an opportunity to activate.

3. Assuming that Outsider is juniorl aircrew, perhaps he is uncomfortable with taking a necessary but courageous action to over-ride and would rather go with the flow and take his chances. If Outsider is in a command position, perhaps he is uncomfortable with the concept of a junior pilot forcing him to go around, but his posts lead to my belief that CRM is not his strong suite.

4 Apologies to Bubbers if I have mis-attributed your motivation.
Aplogies to Outsider if I have mis-identified your motivations.

[One Outsider]

Bubbers posts are mostly about himself. And nothing else.

[Capn Bloggs]

Outsider, pity the Asiana PNF didn't do what Bubbers did.

[pontifex]

I think we are beginning to see a trend that has long been predicted by us greybeards and ignored by bean counters in all walks of aviation. A GAPAN working group of the Education and Training cttee warned of it in a long and comprehensive report. One of the issues discussed was that, with the increasing use and dependence on automatics, when they fail or ( more likely) are misused, the ensuing pilot intervention requires a more highly skilled hand than would have been the case in the past simply because that skill will have been degraded by long term lack of practice. Current policies ensure that that skill will be unavailable.

[safetypee]

Bloggs … “pity the Asiana PNF didn't do what Bubbers did.”
Yes of course with hindsight, but can you explain why Bubs (or you) did, and 'they' didn’t? And then with that understanding, explain how other pilots might avoid such behavior in future situations.

If you stop investigating when you identify what did/did not occur, (is failure to GA a root cause, blaming the human?), it can block opportunity for learning from an event.
Alternatively if you seek the underlying contributions to human behavior, those aspects which might influence situation assessment and decision making, then even though it might be impossible to determine the precise details of this accident, it should enable thoughts about training, operations, and ways of thinking which might just help avoid our own close call.

How do you turn hindsight into foresight?

[bubbers44]

I can see how some pilots here believe being agressive to avert an unnecessary incident or accident is a sign of being over controlling in a two pilot cockpit. I think both pilots should make sure the flight is safe, not just one and the other just agree.

Our recent SFO example states my case. I don't care what OO thinks of my standards of taking care of business but flying hundreds of people in an airplane is serious business and must be dealt with accordingly. Blaming the glide slope being out or the autothrottle didn't work as you thought it should or being 30 knots slow is not an excuse.:=

[safetypee]

bubbers, there are many shades of command and practice, hopefully all with the same objective of safety. However, neither by seeking blame nor making excuse will help improve safety, which from this incident and similar appears to be necessary.

One small move in that direction is for those who hold strong opinions on what they did or will do, could provide details of why and ‘how to’; to describe those aspects which trigger a realisation that an approach needs rescuing and how these aspects are defined and assessed.
An alternative is to consider ‘what if’, to identify the factors which might influence the human for both good and not so good decisions, then defend as best able against the not so good.

In this incident the thread has cited the crew for not making a go-around decision; whereas the alternative view that consciously or unconsciously they decided to continue, may provide greater understanding of the problems.

[bubbers44]

Also, I don't know it all, but 23,000 hrs of flying helps understand how things work and some of the new guys could listen to what their captains tell them that Embry Riddle didn't teach. I went there too but didn't learn how to really fly until I left. Amazing how books and airplanes actually flying are different.