CRJ down in Sweden

[PENKO]

A very sad read, I feel for the crew. This underscores what I have been taught in de sim after the AF accident: you have to compare ALL indications when faced with unusual attitudes, never instinctively react to just one parameter.

If your PFD shows a ridiculously large nose up pitch angle then your airspeed should decrease. It is impossible for the speed to remain stable with such a pitch angle. If it does, something does not add up...

[IcePack]

Very sad but at that time of night most would be startled. But again it shows how modern cockpits & automation has eroded basic flight skills. Something I found coming from a more basic type where a good instrument scan was natural. To tunnel vision as everything you need is on the PFD. Methinks in the past a artificial horizon failure woul just cause a que? Moment as your instrument scan (more like a total look) would immediately alert you to it not being right. I realise the pfd saves the big scan but think it is a human brain thing. More human research should have been done before creating complex displays.

[alf5071h]

This was an accident stemming from a 'hazardous misleading display', which according to AMC 25.1302 2.1 requires that 'The probability of indication of dangerously incorrect information without a warning being given should be Extremely Remote'.

We might ask why the certification process involving the equipment manufacturers (IRS and EFIS), the airframe and simulator manufacturer, and various national regulatory authorities involved in certification did not identify this hazard. Was the probability proven by numbers, or risk assessed such as the crew were expected to notice (regulatory generated black swan).
The EFIS software appears to have been designed to remove the alerts, the accident was 'as designed'; thus how did the various checking processes fail to meet the safety requirement.
The above questions are easy to ask with hindsight, but how might these aspects be turned into foresight.

Is the current emphasis on LoC training, immediate action, and SOPs now biasing pilots to react with little thought, no crosschecking, particularly in surprising situations.
Is the industry generating this type of accident, misunderstanding or seeking to address the difference between what is assumed to happen against the reality of rare accidents, with unrepresentative regulation.
Can the current safety and regulatory processes be expected to identify and manage events beyond the certification boundaries.
There are many approaches to safety, all necessary for achieving the current high level of safety, but is their more recent application now endangering future safety. Regulatory restraint, 'SOP for everything', and train for 'everything', except that not everything can be foreseen, offers diminishing safety return. There is greater need for the interpretation of requirements for training, emphasis on a checking mentality vs educating and understanding, which if misapplied decrease the opportunity for experience further weakening crews' ability to manage the unforeseen. This accident may have been foreseen, but it was parked the other side of a regulatory line 'of assumption' to become 'unforeseeable', yet still expecting crews to manage the surprise when it happens.

Time to change the way we think about safety.

[TowerDog]

Time to change the way we think about safety.

All they had to do was a quick cross-check. If the right and st.by displays were in agreement, keep flying normally. Switch source on the left, or turn it off.
No idea what they were thinking...

[cappt]

The old aviation adage applies today just as it did yesterday. When your surprised by something unusual often the best thing to do is nothing.
Thanks for the update.

[semmern]

Sit on your hands and count to ten. One thinks it would have helped save the day, but who knows. The Swiss cheese holes are lining up in more and more accidents.

[andrasz]

No idea what they were thinking...


The final report is chillingly clear. PF startled by the aural warning and all the blue on the PFD instinctively pushed the nose down without thinking. PNF seeing correct display was totally out of the loop on why. All this in the small hours on a 5th & last leg, with cockpit lights on for the approach briefing during a pitch black night with zero outside visual references. By the time they started to get their act together the situation was beyond recoverable.

[peekay4]

We might ask why the certification process involving the equipment manufacturers (IRS and EFIS), the airframe and simulator manufacturer, and various national regulatory authorities involved in certification did not identify this hazard.

Here we have two different hazards, and by design there's logic that gives priority to one of the hazards (unusual attitude) vs. the other (instrument miscompare). There are a number of risk-based assumptions in creating that priority list, which now will need to be revisited.

[TowerDog]

,
No idea what they were thinking...

The final report is chillingly clear. PF startled by the aural warning and all the blue on the PFD instinctively pushed the nose down without thinking. PNF seeing correct display was totally out of the loop on why. All this in the small hours on a 5th & last leg, with cockpit lights on for the approach briefing during a pitch black night with zero outside visual references. By the time they started to get their act together the situation was beyond recoverable.

Yes, I read the report and my initial thought was: What were they thinking?: Right side agreed with the St.by instrument. Fly the right side, ignore the left side.
Pretty basic, but yes, I understand they were tired, lights were on, etc, etc.
Well, too late now and there is lessons to be learned here: Same as in basic training: Fly the good side, don't rush too into action, etc.

[jack11111]

When you have a mechanical gyro in the center of your panel in the back of your mind maybe you might think "My attitude gyro just died".

The beautiful Integrated PFD's are just so convincing.

[Skyglider]

There are warnings on both PFD's if the two PFD's differentiate (PIT, ROL, HDG). Those warnings were absent since the two PFD's went into declutter mode, because of the unusual "false" attitude on PFD1.
The simulator the 2 pilots regularly trained on, had those warnings present even in declutter mode. But not the real airplane, manufacturer was criticized by SHK.

The probable cause why they didn't check the standby attitude indicator, was that they were subjected to - 1G to +3G & many auditory and visual warnings.

Google translate from the final report by SHK:
"That none of the pilots of the situation verbally referring to standby attitude indicator can be explained by the two experiencing a complex situation because of the varying G loads and a great amount auditory and visual warnings. This has probably contributed further to cognitively
tunnel vision and focus on each PFD."

It's easy to be a hot-shot pilot in front your computer! But if you read the whole report it's more understandable why it happened.

[JammedStab]

It's easy to be a hot-shot pilot in front your computer! But if you read the whole report it's more understandable why it happened.
Exactly. Hearing what the fault was first and then knowing exactly what to do is not the same as an instinctive reaction to an unusual presentation on your PFD. I suspect most would at minimum, make some kid of significant input to an unusual attitude suddenly presenting itself.

[Wrist Watch]

Always happy to see the could-never-happen-to-me-itis in post-occurrence threads.
Hindsight is always 20/20; after every accident you can say oh all they had to do was x, etc...
The rational brain is suppressed in situations like these.
The only way to deal with them is frequent high-stress training and accumulating as much of theoretical knowledge as possible.
Take a look at this (what they were seeing):

https://i.imgur.com/I3JhewY.png
© Swedish Accident Investigation Authority | Creative Commons Attribution 2.5 Sweden

Alarms screaming at you, negative G's hitting you, you don't know what's happening, adrenaline rushing through your body with your body clock asleep, no outside visibility, you're disoriented; yes, I can definitely see them losing it. At that point it would've been difficult to recover. I agree the initial reaction was not supposed to be so swift as the flight was smooth and stable but what do they teach us: never trust your senses in LVC, your ADI is your life. And this instrumental piece of equipment, which was guiding the pilot his whole life without error and which had earned his deep trust, ended up betraying him.

To include the (only) two recommendations:

Ensure that the design criteria of PFD units are improved in such a way that pertinent cautions are not removed during unusual attitude or declutter modes.How about instigating additional and more frequent training including curricula concerning human performance in distress, communication, crosscheck, unusual attitude recovery, high altitude flight dynamics...

Ensure that a general system of initial standard calls for the handling of abnormal and emergency procedures and also for unusual and unexpected situations is implemented throughout the commercial air transport industry.When you have a 'STALL, STALL' warning yelling at you for a full minute and you still don't figure you're in a stall, we have a different set of problems to solve.

It's easy to shove it on the two fellows who can't defend themselves and call it a day, but remember, a fish rots from the head down.
The next time you load up and takeoff, know that the fish is still rotting and the clock is ticking. 'Safe flight.

[truckflyer]

"the fact
that there was no training method for effective communication in an
unexpected or abnormal situation and that the crew therefore had not
practised this contributed to the crew not being able to jointly identify
the problem in time"

The operator has to be the main culprit here, not having a training standard that at least addresses this BASIC CRM issue.
Any "normal" fault detection should at least be confirmed by 2 or more parameters, and cross referenced between the crew.

Both crew was relative "low experienced" guys, however in my opinion the operator does not seem to have had a sufficient high standard of training, leading to an event like this being allowed to happen. Basic CRM and Error fault management seems to have been completely lacking.

[ATC Watcher]

Wrist Watch : Always happy to see could-never-happen-to-me-itis in post-occurrence threads.
Hindsight is always 20/20; after every accident you can say oh all they had to do was x, etc...
The rational brain is suppressed in situations like these.

Absolutely. Fully agree with you .
After an accident ,Humans and pilots in particular always tend to (and like to) go into a safe protection mode : "this will not have happened to me " . We all have this .
Writing about it here brings nothing except perhaps make themselves feeling better.

We have numerous human factors studies explaining you the "why" and "what" happens in your body/brain when faced into a extreme highly stressed situation . Listening to multiple audio warnings and blinking warning lights rather add to the confusion/stress rather than helping to solve the problem . So I always get a bit annoyed when I read that : " they had a stall warning and did not react as they should have ...etc..."

Likewise, focusing on a single wrong display in isolation and being mind set in correcting it, disregarding other options, is a well known phenomena, known to be aggravated when occurring in middle of the night.
The 3 Miles Island nuclear accident report covers it quite well.
More recently the AF447 BEA report mentions it as well.

What make some posting here so sure they would not be subject to the same human factors ?

[truckflyer]

The fact that it took 80 seconds from flying a fully serviceable aircraft, until it was all over, in itself is a chilling factor!

And it's true I believe, it could happen to us all, if the Swiss Cheese holes lines up correctly, it's easy to be keyboard experts. Let's not mention the F or S word, because of course nobody wants to ever acknowledge that.

[Onceapilot]

Yes, a very sad event. It is disappointing that these guys were not effectively trained to a standard that is required to operate the aeroplane at the safety factors required by its certification. Sad, and a hard lesson for others to learn from!

[andrasz]

One thing to keep in mind that as much as we'd like to think otherwise, all humans are NOT created equal. We have people with above average skills and cognitive abilities, and people below average. The top 75 percentile will pass any exam designed for the average, the pilot profession is no different. Automation, SOPs and CRM have made enormous advances towards ensuring that the real-life performance of those with above and below average skills are not that far apart anymore. However there always be the odd unexpected situation where superior skills save the day (Sully) and below average skills lose it (AF or this one).

The direct cause in this case was the PF reacting subconsciously to one piece of information, which was seeing a big and increasing piece of blue of the PFD, no doubt the result of many hours of training and conditioning to follow the ADI regardless any sensory illusions. It would have required that extra touch of superior skills given the circumstances to grasp that if speed, altitude and power setting did not change, the indication must be false.

Given the rarity and unforseeable nature of such failures, it is very difficult to effectively train for them, as by their very nature the required action goes contrary to what one was prmarily trained to do. On the other hand, I'm sure everyone who have read the report will sit on their hands for a few seconds in a similar situation. It is a matter of learning from and avoiding other's mistakes.

[Onceapilot]

IMO, to handle the situation in this event only required training to be able to perform at the minimum standard of skill for being qualified to operate this aeroplane. This event did not require non-standard superior skills to resolve safely, just the correct proceedures! INU failure or Instrument comparitor warnings are not rare or "unforseeable" failures, I have experienced several, including one at night IMC after T/O as PF, and they will continue to happen.

[MurphyWasRight]

The direct cause in this case was the PF reacting subconsciously to one piece of information, which was seeing a big and increasing piece of blue of the PFD, no doubt the result of many hours of training and conditioning to follow the ADI regardless any sensory illusions.

Given that it was middle on night the PF may not have been fully aware of how fast the display had changed.
Even if fully awake he may have had the sensation of having nodded off for a bit so would be less likely to suspect a technical fault.

Anyone who has ever had a close call (or worse) with falling asleep while driving knows the feeling...

[Chronus]

Extract from the ACCIDENT REPORT:
"According to the aeroplane’s manufacturer,
the autopilot was most likely automatically disconnected due to
differences in the pitch servo commands. The aural warning remained
active for the next 18 seconds."

There were three pilots on board, PF, PM and AP. Once the one who did all the work decided to quit the job, the other two could not handle the situation. I put it down to yet another case of total capitulation to automation.

[andrasz]

Even if fully awake he may have had the sensation of having nodded off for a bit...
They were doing the approach briefing, so this is not likely. He knew that his attention was elsewhere for some time, and was completely startled by the unexpected change in the display when looking back. As several posts earlier noted, with the benefit of hindsight it is easy to say what should have (not) been done, but I really wonder how many would have fallen for the trap under similar circumstances.

[MurphyWasRight]

andrasz:
They were doing the approach briefing, so this is not likely.
Thanks for correction, have not had time to read full report.

May still be partly a 'my fault? technical fault?' decision with known distraction pushing the 'my fault' branch.

Of course even if 'my fault' the correct action is not necessarily immediate extreme corrective action in the same way that swerving to get back on the road is much more dangerous than the initial drifting off.

As others have pointed out it is much easier to see all of this from a calm place in front of a keyboard.

[Livesinafield]

Some real hero pilots here sat typing from the comfort of their laptop keyboards...

Unless you have worked for the operator then you know Jack about the training so please learn a little respect.

The crews that WA have are very good stick and rudder pilots, this event could have happened to anyone...in the middle of the night half asleep at the controls it's a different storey than sitting in your armchair in front of a keyboard ....

[megan]

+1 Livesinafield.I really wonder how many would have fallen for the trap under similar circumstancesA few have andrasz. Brave person to put up his hand say couldn't happen to me.

There is nothing new under the sun, for those who wish to criticise rather than understand, some previous accidents brought about for exactly the same reasons.

Korean Air Cargo Flight 8509 - Boeing 747, Stansted
Air India Flight 855 - Boeing 747, Bombay
Copa Airlines Flight 201 - Boeing 737, Panama to Cali

Possibilities

Pan Am Flight 816 - Boeing 707, Papeete
Viasa Flight 897 - DC-8, Portugal

[Uplinker]

At every SIM we always have to do an EFATO, a OEI ILS to a go-around and a OEI NPA to land.

In the light of recent accidents, I think that two other mandatory elements should be added to every SIM from now on:
1. Unusual attitude recovery.
2. Primary instrument failure, identification and recovery.

Pilots should of course be able to fly manually. (I have flown Southampton to Prague with no autopilot - and it is possible, but very tiring, keeping to +/- 200' for 2 and a half hours). However, there is no getting away from the fact that skills become rusty if not used. In addition, some situations such as AF447 have never been seen by most pilots. (see my post #1119 in the AF447 number 12 thread).

It is all very well writing words on a page in the FCOM/FCTM about how to deal with a problem, but another prospect entirely to recognise and deal with a possibly complex, confusing problem, with no external cues, no previous practice and no warning.

If you showed a concert violinist a piece of Stephane Grapelli music, (jazz violin), and let them read it as much as they wanted, but did not allow them to play or practice it even once; how would it sound the first time they were asked to actually play it? Perfect, or awkward and stilting? Being different from the concert music they were used to, they might not initially be able to play it at all.

In reality of course, the concert violinist would practice the music on their violin over and over again at home before performing it, but we cannot take our airplane home, or use the SIM to practice, and yet we are expected to be able to recognise and react correctly to every possible situation, even if we have never experienced it at all.

[TowerDog]

Several posters referring to keyboard warriors as in suggesting that nobody could have survived an instrument failure and everybody would have died in the same scenario.
:mad:
This scenario has been along for year: One side goes to :mad:, look at the 2 other attitude instruments and compare. Then fly.
Had it happened at night over South America in a B-767.
The secret to survival in this business is to learn from other's mistakes, not just your own. Many similar accidents have happened in the past, hence quite a few companies practice this in the simulator as well as unusual attitude recovery.
It can be confusing, but that is what we train for and get paid for, the good, the bad and the ugly.
This malfunction was very survivable: Compare instruments, rignt side is good: "you got it, you fly it".

[alf5071h]

The report gives a comprehensive overview of the limitations of human performance, but then by inference, cites the human as a cause by requiring more procedures and training.
More callouts and procedures are unlikely to be effective, particularly in situations where human mental resources are minimal and also because hearing degrades before the other senses.

Many (most) LoC accidents involve misunderstanding a complex situation, and based on this, inappropriate action results in upset conditions; the aircraft were not 'upset' to begin with. Also, each crew member's understanding appeared to differ such that it was impossible to communicate helpful information, at least until the event progressed, often to the point on no recovery.

Because of the human limits we should not expect to see any cross monitoring or CRM in this type of accident. This is an important safety issue particularly as the industry increasingly relies on these safety aspects, in extreme situations like in this accident they may be unavailable.
We cannot expect the humans to cover for system failures in remote or confusing situations. The reliability of modern technology is now so good that when it cannot function (extremely remote), neither can the human. Furthermore, because it is difficult to identify the circumstances and contributions associated with 'extremely remote' events beforehand, it is unlikely that we can provide targeted training; and why train for the last accident which may have no relationship with the next one (excepting the need for improved awareness and surprise management).

The industry should also consider other less obvious factors which could influence pilot behaviour. E.g. how is upset recovery training taught, has the industry over promoted quick reactions to make a nose-down control input, what scenarios are trained in the simulator.
These 'minor', apparently inconsequential contributions could be disregarded, but in extreme circumstance they may be a significant, although not an immediate apparent aspect. The industry has to be aware of 'Meldrew moments' * "I don't believe it'.

This is similar to citing human error as a cause, which should trigger the need to look deeper in the accident; thus any potential contribution judged "I don't believe it ...' should be reconsidered, look deeper for underlying assumptions associated with a less obvious contribution.

* 'Meldrew moments' (MM) from a British tv comedy involving the catchphrase "I don't believe it'.

[Mad (Flt) Scientist]

@ Uplinker
In the light of recent accidents, I think that two other mandatory elements should be added to every SIM from now on:
1. Unusual attitude recovery.
2. Primary instrument failure, identification and recovery.
The first of those already exists, and was even started at the operator (1.18.3 in the report details this - the requirement was going to be effective in May, the accident happened in January; the operator had started to train their crews in anticipation, but these guys hadn't had that training yet). Would it have made a difference - who knows?

[TowerDog]

. Would it have made a difference - who knows?

Quite likely.
If you see something in the box one day, then see it on the line the day after, you already "know what to do".

[safetypee]

T D, it's not as simple as you suggest; biased by hindsight? (#279)
We cannot assume that pilots will understand the situation as requiring a cross check.
The PF may be concentrating on what appears to be a sudden pitch upset manoeuvre, the PM surprised by the PF nose-down response, where the situation according to PM apparently requires a nose up manoeuvre, and not necessarily seeing the comparator alert.

The pilots cannot deduce that 'the right side is good' without comparing both EFIS with the stand-by ADI and then confirming which two displays agree; this takes time and mental effort, neither of which may be immediately available.

Trained for confusion, or confused by training. There is a level of confusion where the human cannot manage.

[TowerDog]

. T D, it's not as simple as you suggest; biased by hindsight? (#279)
We cannot assume that pilots will understand the situation as requiring a cross check.

They should, this is pretty basic.
Why does some people think it is hard or extremely complicated?
Basic instrument flying, nothing more.

Some of you guys are confusing me: Does a failed screen or attitude indicator justify a death sentence? Is it like loosing both wings and the tail at FL350 over the Atlantic in the winter with no parachute?

NO.

The airplane was perfectly flyable, all they had to do was fly it.
Why do we even argue or disagree?

[safetypee]

The certification requirements require the combination of false IRU information and the inability to display a comparator warning be extremely remote(Alf #280 and previous): where -
'Extremely Remote Failure Conditions are those not anticipated to occur to each aeroplane during its total life but which may occur a few times when considering the total operational life of all aeroplanes of the type.'
And
'Extremely Remote Failure Conditions are those having an Average Probability Per Flight Hour of the order of 1x 10-7 or less, but greater than of the order of 1 x 10-9.'

However the particular EFIS design removes the comparator display for pitch values (true or false) greater than 30deg, thus the loss of display and warning is not a combination of two failures but just that of the IRU.
The reported in-service IRU failure rate was less than the required combined value, thus should be considered as not meeting the requirements.

[RAT 5]

Surely, or am I being too simple as I've never experienced it, but does 'seat of the pants' come into this analysis somewhere? Hugely difficult if you've spent all your life relying on your eyes; I know. Do we always need a comparator to tell us something is fishy?

I've never been given a frozen attitude or incorrect attitude instrument in recurrency training. I'm sure it would be hugely positive and rewarding, but sadly most outfits lack imagination. The UA box ticking is no big deal, and the new airspeed unreliable procedure frustrating and time consuming before you arrive at the correct input which you should have known all along. The first scenario is recall and piloting, the second is QRH driven.
In this scenario they guys would have had to be very smart & very disciplined without panic. If it goes inverted while you are trying to figure it out, doesn't help.
Why don't we experience some 'limited panel' flying in todays jets? It will teach you a great deal about your a/c and your own strengths & weaknesses. Is it because of "it ain't supposed to happen" thinking?
IMHO training in pre-planned scenarios with pre-planned responses has limited values. In-depth training to understand the a/c & yourself gives a broad solid foundation to apply in a multitude of unforeseen scenarios. The STN B747 was a simple frozen ADI, which caused a crash. It is not the only crash from such an apparently simple isolated failure. I say simple because the PM has correct data confirmed by all the basic performance instruments. It then becomes a CRM and handling exercise; to arrest the situation before a crash.
Never seen it. What a waste of simulator time; an ideal opportunity missed to gain real positive training, and avoid that confusion.

[alf5071h]

Tower Dog, not wishing to compare you to Victor Medrew (post 280), but confusion (failed screen etc) is a symptom of disbelief.
Many people could not believe AF or Colgan, but more often the simpler view is more relevant. Humans can be maxed out and in those circumstances they do what some view in hind-sight as 'unbelievable', but at the time, momentarily, was perfectly reasonable for the pilots flying the aircraft.

RAT, 'seat of the pants', yes and pitch trim to fly the aircraft. But there again when the brain is maxed out then the senses may not make sense, even if ever observed consciously.

[TowerDog]

. Many people could not believe AF or Colgan, but more often the simpler view is more relevant. Humans can be maxed out and in those circumstances they do what some view in hind-sight as 'unbelievable', but at the time, momentarily, was perfectly reasonable for the pilots flying the aircraft.

AF and Colgan, Yes you are right, unbelivable. Perfectly good airplanes being flown into the ground, or water.
Not being Monday morning quarterback or kicking dead colleagues, got lots of empathy because in many cases, I have been there, done that but survived.
Could tell stories all day about the flying I have done in old and tired airplanes over 37 years in the third world countries with bad maintenance, etc, etc.
This is not about me however, maybe I was lucky, or had a strong fear of dying, or both.
When I see people flying perfectly good airplanes into the ground however, and people on the Internet cooking up excuses about confusing situations or it could have happened to all of us, I tend to disagree and get sad, most of these are so damn unnecessary and you don't have to be Chuck Yeager to look across the panel and see if "his side is good" or with Colgan, add power and push forward on the yoke.
Guess my life is pretty simple.

[IcePack]

The reason TD is that you were brought up & have many hours on 37 year old aeroplanes. The latest pilots don't have that experience & have most of their flt time using modern instrumentation.

[F-16GUY]

When I see people flying perfectly good airplanes into the ground however, and people on the Internet cooking up excuses about confusing situations or it could have happened to all of us, I tend to disagree and get sad, most of these are so damn unnecessary and you don't have to be Chuck Yeager to look across the panel and see if "his side is good" or with Colgan, add power and push forward on the yoke.
Guess my life is pretty simple.

Its not that simple TowerDog.

Although the pilots in the cockpit and their actions directly relates to the outcome of the situation, there is a company behind, and a regulator behind the company. The regulator has the ultimate responsibility to establish safe minimums for the required training, both with regards to achievement of initial qualification, but also with regards to onwards training with the goal of sustaining a certain level of piloting skills and airmanship. The regulator also have the responsibility to assure that those minimums are adhered to by the company. The company on the other hand has an obligation to provide its crews with the best possible training, but since money makes the world go round, they will most likely only be interested in meeting the minimum requirements.

So as I see it, the regulator is at fault by setting the bar to low.

[RAT 5]

One problem I see in todays world of training to minimum requirements is this; the trainers try to beat into crews A.N.C. but, they are also taught to beat in to the crews every time there is a problem, PF "state malfunction." PM does his best and with conformation of PF a QRH is called for. This is the rote of training. DoNot act as a cowboy, on your own, outside the checklist.
So now you have a scenario where nobody has a clue what is going on; the a/c is hurtling terrain-wards; is still controllable if you're quick and decisive, but by whom?? Ah, the big question. Somebody has to make an executive decision and decide what to do without a checklist and the usual nice calm process. There is a bull that has horns that need grasping PDQ. This goes against all the training rituals, but it is pure survival and the brain of some will be confused by the conflict and feel rudderless.
Those of us brought up in a less stringent era, and more pilot orientated, will not feel as restricted about doing whatever is necessary and argue the toss later on. I often found the modern youngsters, when faced with a piloting situation for which there was no black/white SOP or QRH, hesitated. Not their fault, but a training system fault. They had forgotten how to think as pilots first and crews of XYZ second. Normally they can succeed with the latter, but occasionally circumstances combine to thwart your coziness, and the former is required. That attitude needs to be there or you will flounder on the rocks.

Me thinks this debate has been had many times before on here; perhaps more general, but still the same subject. It comes around more than anything else.

[F-16GUY]

Me thinks this debate has been had many times before on here; perhaps more general, but still the same subject. It comes around more than anything else.

Agree, but for some reason nothing (or very little) is done about it by the regulators. I am of the impression that the beancounters have persuaded the regulators that the price we (as a profession) are paying now, is the price of doing business, and the regulators have accepted this offer on behalf of all of us.

[TowerDog]

. So as I see it, the regulator is at fault by setting the bar to low.

And the pilots have no responsibility for thinking outside the box, for surviving a TV screen going bad and for basic flying skills?
They can only do what they are thought and nuthin else?

I disagree, but I am from a different area I guess and those years flying bush in Alaska without no books and with no "training" made me look different at flying airplanes. As in "Do whatever it takes" to go home and have a beer.

Enough said, not going to argue anymore, different times I guess, and a good thing this was a cargo flight: A lot less dead bodies being scattered around the tundra in Sweden because of a faulty image generator.

The reason TD is that you were brought up & have many hours on 37 year old aeroplanes. The latest pilots don't have that experience & have most of their flt time using modern instrumentation.

Yeah, time in DC-3 and DC-8s did not hurt my stick and rudder skills, and believe me, old airplanes have their own set of demons built in, and one tend to play the "what if" game on long and dark flights: What would you do if this or if that happened? Kept us awake and sharp on systems and emergencies.

Most of the time we were too tired, 30 hour duty days, bunch of time zones.:sad:

.Those of us brought up in a less stringent era, and more pilot orientated, will not feel as restricted about doing whatever is necessary and argue the toss later on.

Bingo, that was all about surviving, not about stepping on some stupid rule or procedure made up to hold the hand of the weakest link in the cockpit.

[F-16GUY]

And the pilots have no responsibility for thinking outside the box, for surviving a TV screen going bad and for basic flying skills?
They can only do what they are thought and nuthin else?


Of course they have some responsibility, but the problem is that from their first flight at a civilian flight school, they are placed in an environment and thought a mentality that does not prioritize or foster basic pilot skills like the skills you earned in the bush. For many young pilots, this is unfortunately and not by their own fault, their understanding of aviation.

I wonder how many of those involved in accidents like this one, Collagen and AF447, actually spent their first 1000-1500 hours piloting an aircraft equipped with a minimal level of automation, thereby learning basic aircraft handling by heart. Instead we now have crews piloting complicated machines with high level of automation, while having as low as 250 hours of real stick and rudder time under their belt. And after 2000 or 3000 hours on type they are considered experienced although their total stick and rudder time still rests at 250 hours plus a few minutes on every second flight. Furthermore, the needed skills will diminish over time, and both pilot and more so their company and regulators have a tremendous responsibility to do something to maintain it.

[F-16GUY]

Perhaps a bit more 'what if' while sitting idly in the cruise or keeping up to speed with that long list of memory drills might help? Sometimes sitting and analyzing rather than jumping to coclusions and starting incorrect procedure would not go amiss.

Yes, but apparently that part is not thought well enough to some pilots, and the fact that they are not "what if'ing" is not caught in the sim during recurrent training.

[TowerDog]

. Of course they have some responsibility, but the problem is that from their first flight at a civilian flight school, they are placed in an environment and thought a mentality that does not prioritize or foster basic pilot skills like the skills you earned in the bush. For many young pilots, this is unfortunately and not by their own fault, their understanding of aviation.

How do we fix it?
Much higher age/hour requirements maybe? Not with a looming pilot shortage, the airlines would be screaming for more warm bodies in the right seat, at whatever cost, just fill the seats..
(One of my buddies is a sim instructor for a well know LCC, now teaching primary guys on the B-737 with 160 to 180 HR total time, then they get spoon-fed from there and into the cockpit of a real 737-800 with 190 pax. Bon Voyage, hope the old man does not get a heart attack)
In my world, I had 5300 hours total time before climbing into a jet the first time, 31 years old. Late bloomer perhaps but I had practiced staying alive for 10 years after I got my Commercial Pilot License.

Don't have the answer, but if I was in charge of training or recruiting, I would look for survival skills, rather than book skills.

[MrSnuggles]

Sorry to chime in like this, but this is an area in which I have knowledge. So, my two cents...

I'm really really sure that the regulator in Sweden has all kinds of standards set and measured. I promise you that if someone does it the German way, it is Sweden. Sure, there might be some kind of oversight somewhere, but if there was ever someone to learn a lesson from others regarding unusual attitude cockups, be sure the Swedes had it covered by Jan 1st 2010.

No, what I think is more likely is the trend of misunderstanding the given information, or a lack of interpretation or imagination of what is happening. Airplanes, like cars!, are being more and more complex and require more tuning to comprehend. That is what is deadly.

Remember that in the early days, crashes were often caused by mechanical malfunctions. Clever design and improved skills in building has minimised those incidents. Now, it is the human that is lacking.

[megan]

you don't have to be Chuck YeagerTD, even he belled the cat on one occasion, wrote off a perfectly good aircraft, and very nearly lost his life because his instrument skills were not up to the task in hand.suggesting that nobody could have survived an instrument failureI don't think anyone is suggesting that, what they are suggesting is it's another gotcha that has befallen others, and a possibility for those now living to fall into the same trap.

[TowerDog]

Remember that in the early days, crashes were often caused by mechanical malfunctions. Clever design and improved skills in building has minimised those incidents. Now, it is the human that is lacking.

Yup, I agree Mr. Swede. You hit the nail on the head.
Airplanes these days are pretty damn idiot proof and reliable, but us being humans, we can still cock it up, and we do. Coltan, AF, Bolivian RJ 85 and many others.
None of us are bullet proof. Had a few close calls being fatigued and too greedy to call it quits. My bad, and a bit of luck.
One learns from experience, sadly these low-time guys who crashed the mail flight in Sweden were just hanging on, not much experience to learn from and the Luck Bucket went dry.
R.I.P. Gentlemen and to the rest of you rookies: Pay attention and get ready for a high tech airplane wanting to kill you: Stay one step ahead and be slightly paranoid.

[Uplinker]

Uplinker:
In the light of recent accidents, I think that two other mandatory elements should be added to every SIM from now on:
1. Unusual attitude recovery.
2. Primary instrument failure, identification and recovery.

Mad (flt) Scientist:
The first of those already exists, and was even started at the operator (1.18.3 in the report details this - the requirement was going to be effective in May, the accident happened in January; the operator had started to train their crews....

In 16 years of airline flying and SIMs with two airlines, I have never had unusual attitude training or even practice in the SIM.

[ehwatezedoing]

It's not much of an "unusual attitude" from the aircraft itself.
Than "just" a flight instrument(s) caking on you, and you would still continue straight and level without any actions from your part.

Figuring that out when it happen can be the hard part.

...If you see what I'm trying to mean...

[darkbarly]

Read and reread the report and still I find something troubles me, the initial reaction timing. According to DFDR elevators were moved by PF at T3, this being 3s after the failure and 1s after the AP disconnect. By this stage, yes, the PFD had risen to 13.7deg PU, so a very rapid pitch (indication) excursion, significantly greater than would be seen (and believed) in normal ops.

Nevertheless, why did PF respond so quickly ( 3s is quick) without ANY somatogravic change of state? I am puzzled by this and it is not explained directly in the report.

It worries me to think that it is within the scope of normal pilot behaviour to react instantaneously to a major change in the displayed flight trajectory without 'feeling' it also. Let me be clear, this is not about som. Illusion or recovery from UA.

[RAT 5]

People ask what is the regulator doing? Too often they are not that knowledgeable about our job. They know all there paperwork stuff, but they are not always that experienced as jet pilots. They set minimum standards, very bare minimums, and hope the conscience of the airlines raises their own bar. Some hope. Some airlines think that increased training = increased quality. Not always so. More button pushing does not mean more understanding of the a/c nor more handling skills as a pilot. I find it disappointing that a company gives a few moments of manual handling in the recurrency sim every 3 years, but discourages the same on daily line ops. Lip service. Setting higher minimum standards in the basic TR might be a start.
I have a trainer friend in a national carrier. On their TR courses, be it new cadets or type conversion company pilots, they give the 1st 3 FFS sessions as basic flying. 1st session no automatics or FD's; 2nd session add in FD and some automatics; 3rd session look at all aspects of AFDS and some hiccups. Once that is all understood they then add in all the non-normals & emergencies.
In other operators, whose training is considered good, during the TR course the amount of FFS has been reduced and the amount of basic flying, outside of LST items, is about 30mins. The amount of CMD operating has been increased. It is an astonishing 'poles apart' difference in thinking. If you are a 150hr cadet in one of the latter what chance do you have to learn basic piloting skills, especially as line flying is primarily in CMD at all times.
If the XAA's insisted on FFS 1-3 being the basics of manual a/c control the airlines would have no choice. If command upgrade courses required a demonstration of basic skills to a high standard, the airlines would have no choice.
Leaving everything to the airlines will not create a common industry high standard. The basic LST is simply that; a very basic standard. We need a higher basic level.

[deadheader]

Just to touch on some of the very well made comments above, my simple yet serious query is thus:

Are some commercial pilots now so far removed from the physics of flight/aerodynamics that a simple flight system component failure can more easily result in LoC?

No disrespect whatsoever to those who lost their lives, and to be clear I believe they were victims of the times rather than their own shortcomings (ditto AF447 crew), but, at the moment of indicated attitude change and subsequent A/P disconnect, there were no corresponding changes in altitude, airspeed or vertical speed. The crew therefore diagnosed the problem as one which must have defied the laws of physics/aerodynamics (ditto the AF447 crew).

In other words, the situation the crew assumed they were in, could not possibly have existed. The parallels with AF447 are alarming in this respect.

Additionally, given that an uncommanded change in attitude (& A/P disconnect) is an unusual occurrence, especially during the cruise phase, such an occurrence ought to prompt a logical evaluation of the overall physical/aerodynamic situation before acting, for example; pitch check, roll check, yaw check, power check, altitude check, speed check, VSI check, fuel check etc.

From that point, the issue might have been resolved logically to a successful conclusion.

My personal favourite example of a crew response along the lines of what I'm attempting to convey, and fear may be in decline at least in some circles, is BA009 in 1982. The crew of that flight responded to an utterly unfathomable situation using logic and a thorough understanding of the physics of flight and, as a result, were able to save many lives over the Indian Ocean that night.

All just IMHO of course.

[alf5071h]

TowerDog "How do we fix it ... Don't have the answer ..." It would be brave person who would say otherwise.
Thoughts of survival skills are interesting; these skills are associated with a positive mindset, thinking through difficult situations, being prepared for the unexpected.
Perhaps these are the aspects which regulators should be considering, first about themselves, then safety initiatives and aircraft design, and finally about the operators.

MrSnuggles, "... the trend of misunderstanding the given information, or a lack of interpretation or imagination of what is happening ... complexity ..." Patterns can be found wherever we look (what we find is what we look for), but in this instance the mounting evidence from the small number of rare events must be taken as significant. The industry does not have the luxury of time, nor hopefully, opportunity to accumulate more data, which some safety systems rely on.

The industry should not view the human as 'lacking'; this tends to imply failure and a need to improve or mend a broken system.
In accidents like this, the human is limited by inherent capability. Momentarily, situations are encountered where there is little if any opportunity to improve human performance (like those moments of puzzlement in observing an illusion, choosing a viewpoint, but not necessarily one which everyone agrees with).
The human is not broken or in need of replacement - we do our best as we see the situation. The industry has to recognise those situations where the human could be operating close to performance boundaries, and then minimising the number of occurrences so as not to cross this boundary or by providing a larger buffer space for recovery.

The situation in this accident involved an IRU failure, which output misleading attitude, and in parallel the removal (by design) of the alerting system which identified a difference in flight deck displays; a difference which existed because of the nature of the IRU failure prevented removal of the erroneous attitude display.
Most aircraft can have this form of IRU failure and also use a comparator for alerting; however it would be surprising if all aircraft types remove the comparator in the event of an upset - replies sought please. This is an area for accident investigation and safety management.
If a particular aircraft type is an oddity, then the difference needs to be identified before exposing crews to a surprising and confusing situations.
Certification and operational regulation must focus on protecting the human from extreme conditions, and not to treat a human as a hazard to be constrained, instead, improve situations to better enable them use their unique skills of decision and adaptation.
Perhaps the regulators need a 'comparator' alert in their certification.

A side thought; the IRU is a part 25 system, the CL 600 EFIS ... did that have part 23 roots (pro-line), as used in the Challenger?

[RAT 5]

Your comments reflects back to my earlier question about whether 'seat of the pants' should have been part of the analysis. I didn't fully understand the photos of the PFD in #265. Are these both of the same PFD showing a sequence in display, or are they LHS & RHS? It'll help me understand. As DH asks: if you are in level 1G flight and there PFD says you are in upset flight does your backside not tell you eyes that 'it can not be true'? This is not not about a false level from your inner ear, it's simple g loading on your body.
This situation & experience is a classic simulator training exercise, but in 35 years I've never seen it. It teaches so much: knowing when to sit on your hands; careful analysis of the situation without a checklist; CRM about what to do about it; plus other aspects.
Equally I've never been given blocked static vent (only pitot tube). Simulator being wasted?

[alf5071h]

RAT5, 'seat of the pants' (acceleration), perhaps one of those senses which is degraded in surprising and stressful situations, or during high workload. And the eyes, or the interpretation of what is seen, can lie, this sense can differer or conflict with information from other senses.

Humans do not have a 'comparator' detection and alerting system. At best we might experience similar situations in training and flag the need for caution when encountered in operation, e.g. after 'seeing' (understanding) the Muller-Lyer illusion, it may be possible to identify similar situations and avoid them, not be caught out by the misleading information.
Illusionary effects can be used to aid safety, cf M-L illusion road markings when approaching a narrow bridge; ... but that might not prevent a double decker bus driving under a bridge which is to low; the situation is assessed on where we 'look' and what we 'see' (or wish to see - bias or prepositioning from experience/training)

Most simulators, as good as they can be, are unable to simulate prolonged acceleration, and thus are very weak in creating illusionary effects.

[RAT 5]

alf: Interesting; and hence my thoughts as a question not a fact. I agree about the sim limitations and our reluctance to overcome what our eyes have been trained to do over many years; plus the startle/stress element of such a scenario.
And that brings us back to the use of simulators and showing crews what gotchas & traps are out there; so enforcing your comment about we might experience similar situations in training and flag the need for caution when encountered in operation, e.g. after 'seeing' (understanding). I think simulators are under-used in this way. One can show many real life events in this way. In there briefing phase you can go thought the 'what if' discussion and then demo it and let the crew play; it does not need to be a full LOFT, just enough to get the point across and let them see the dangers and realise the limitations: e..g the blocked static vent on the Peru B757. Let the crews experience what confusion is caused by the instruments appearing to oppose their inputs and 'teach' what to do about it. A full blown LOFT takes a long time, and in that same time you could introduce various scenarios and thus impart a much larger amount of knowledge & understanding for use should any of them ever happen.
After the B777 SFO some TC's said they told their students about the trap in the A/T. Did they demo it? Difficult on the line. How many airlines now include it in their TR syllabus as an exercise? There are numerous other gotchas we've seen, and after the crash of serious incident we discover it was not the first time in the world. After the AB landing in the trees at Basle; how many airlines include that trap in the TR? Did it not happen again in India? Maybe slight differences in reason, but it still landed short of the runway in idea as the crew watched in horror.
How many G/A's have led to crashes, or near crashes, due to a gross out of trim situation of a mis trimming. Enough to introduce it as sim demo exercise don't you think.
I always used to learn more from my mistakes than successes. A simulator is a great tool for showing what can go wrong, how easy it is for it to go wrong, what it looks like when it goes wrong, how to escape from it and how to avoid the trap in the first place.
This goes well beyond the tick box 3.4 on the training syllabus, but it'll keep you safe well into the future.
Let's use the tools we've got to more effect and to their full potential. More training less box ticking.

[Uplinker]

ehwatezedoing
It's not much of an "unusual attitude" from the aircraft itself.
Than "just" a flight instrument(s) caking on you, and you would still continue straight and level without any actions from your part.

Figuring that out when it happen can be the hard part.

Yeah, see point 2 in post # 301

TowerDog. Yes, your 5,000 hours of flight on (I guess) the basic T clockwork instruments has stood you in good stead. Now we have cadets flying about 100 hours on a modern light aircaft and then straight onto a PFD type presentation, and maybe that is the problem - It's not their fault but maybe they can't assimilate it properly.

If you think about it, on a PFD you 'climb up' the pitch angle, the V/S scale and the Altitude tape if you pitch up - to a higher pitch angle, greater vertical speed and higher altitude - and decrease all three if you pitch down, so they all react to pitch changes in the correct sense.

The speed tape though reacts backwards, if you pitch up, the tape moves the wrong way to a lower speed and ditto to a higher speed when pitching down. I wonder if this tape moving the 'wrong' way confuses us on a deep subconscious level? If the speed tape were the other way up, so higher speeds were lower down the scale instead of above, then the speed tape too would react in the correct sense to pitch changes. You pitch down, and you go down the speed tape to a faster speed, pitch up towards a slower speed.

Round clockwork instruments don't have the up and down, but clockwise and anti clockwise movement. If one pitches up, the speed dial rotates anti clockwise, pitch down, it rotates clockwise. Perhaps this round movement is easier to associate with the up or down pitch changes than a 'backwards moving' straight, vertical speed tape is?

[TowerDog]

TowerDog. Yes, your 5,000 hours of flight on (I guess) the basic T clockwork instruments has stood you in good stead.

More like 13,000 hours on steam gauges and 3000 hours on glass.
Yes, I get your point, perhaps glass cockpits with speed tape reacting backwards and everything on 1 screen, makes it less obvious what is going on?

Not sure. Perhaps young pilots born and raised on glass, it would be second nature to them, no idea.
I never liked the glass cockpits and the "boxes", kept fumbling in the beginning.
Still do I guess.
Not my cup of tea.

No idea what the background of these pilots were, but only 3,300 hours each.
Looks like they could have used more time and more training. :sad:

[MrSnuggles]

Uplinker

Yes, research has shown that humans comprehend angular movement as instinct. This means that rotations (of legs or clock handles) are easier to interpret correctly than vertical movement like the speed tape. The same is true of speed on your car. It is easier for the brain to know how fast you are going by seeing the rotation of the traditional round dial speedometer. It is harder for the brain to interpret the digital numbers on the modern display. Remember that numbers are taught in school, but moving around is not! When you are taught the numbers, your brain has already worked out angular movement by instinct for several years!

I am very confused why airplane designers still choose to show speed on a tape when this is known.

ETA: I realise that I may use some words incorrectly. I apologise for any inconvenience this may bring to your inner grammar nazi. :-)

[andrasz]

According to DFDR elevators were moved by PF at T3, this being 3s after the failure and 1s after the AP disconnect


In my reading this is clear proof that the reaction was subconscius, probably the result of a rather rigorous training that indoctrinated the need to follow ADI regardless of what one's senses dictates. This approach and training has saved many a day and made aviation much safer globally than it was 30 years ago - yet in this case it appears to be the direct cause.


I mentioned in a previous post that an above average crew would have had this figured out in no time, however traning is there to bring up below average crews to performance levels of at least average. With a clear repetitive pattern emerging with broadly similar circumstances of crews losing control due to a simle and recoverable fault, it will be interesting to watch how training regimes try to adapt without losing some of the progress that was made.

[Intrance]

@TowerDog:

No idea what the background of these pilots were, but only 3,300 hours each.With all due respect, I think your amount of hours and experience may distort your view just a slight bit. Yes, 3300TT is only a fraction of your experience, but it is still several years worth of flying even if you would hit your yearly limit all the time. Depending on their backgrounds they could have a combined flight experience of 10+ years which is not insignificant... As you know there are planes being flown full of passengers with less experience on the flight deck and often coming from just one of the pilots.

I have yet to read the full report, but from the comments here it does sound like they could have used a background in older planes with steam gauges. Cross checking is second nature there, at least in my experience on the type I flew; "Hmm, my ADI is tumbling away, is yours still OK?".

[TowerDog]

I belive the full report is available right here on this thread.
Everbody could use a few more years or a few thousand hours more in the seat, especially if
Some sinister tv screen failure is anticipated, or not.
If not, stay sharp and be a bit paranoid young guys.
Flying is easy, until it is not easy anymore:
This accident, AF, Colgan and a bunch of other crashes should wake you up.

[oleary]

Canadian Beaufort Sea in December 1979.

Blacker than the inside of a duck in ice fog and darkness.

Aircraft was an Sperry IFR Bell 212.

We picked up off the rig deck into a hover and turned into wind (away from the rig lights).

I pulled collective as the FO called 20', 40', rotate.

As I rotated into the blackness my ADI slowly tumbled with NO FLAG.

I looked at the ASI, VSI and compass. All normal.

I looked at the standby horizon and it was normal too.

I said to my (low time) FO, "I'm losing my ADI get ready to take control if I ask".

This whole thing took maybe 5 seconds.

We flew the a/c IFR for a week with a duff captain's ADI.

Times were different then.

I had a similar thing happen (December again) with a Sikorsky 61 night IFR slinging north of Rea Point, Nunavut (Lougheed Island) at about N 78.

Same result.

FWIW, I am also current on glass cockpits in fixed wing.

[Mac the Knife]

A question for you guys.

Suppose you were bimbling along quite happily at cruising altitude to wherever and you suddenly had an overspeed warning with an IAS of Mach 1.2.

Would you immediately react accordingly (switch off AP, pull back on power, pull up nose - or whatever you do) or would you say "Oh balls! The fricken computer's on the fritz again!".

I ask, because we have lots of monitoring equipment in the operating theater and it does, occasionally, start talking nonsense - one's first reaction is to look at the patient and if they are pink and well-perfused there can't be THAT much wrong. Then you start trouble-shooting the monitors.

Just asking....

[F-16GUY]

Me actually thinks amount of total flying hours is totally irrelevant. What counts is total amount of training received within the not so distant past. Skills erode over time, some faster then others. Pilots need to be exposed to situations that sharpen their basic skills on a regular basis and not for 30 minutes every 6 months.

Sim or actual airtime (without pax) is expensive, so the companies do not have any incentive other than to cut it into the absolute minimum required by the regulator. And regulators apparently dont see it as a big issue yet.


oleary,

It does not count in a chopper. If you see more than 3 degrees bank angle or pitch, you immediately know the ADI is broken :-)

[oleary]

Dunno about that. I have about 8K hours of hard IFR in helicopters, a bunch of that with a sling load. And I have had some of my night slinging trainees manage to get the ADI all white, then all black, then all white again. ;)

[F-16GUY]

I hope they payed you well, cause that would have scared the crap out of me:uhoh:

[RAT 5]

Many guys have commented about failures of system being confirmed by 2 parameters. I've worked for only 1 operator who had that written into the SOP's. It makes common sense. That was in an era before cadets.
Since then, and the during TR courses I've given to cadets, I've tried to suggest that this philosophy should be written into the teaching. No success. Very disappointing. Looking for that 2nd confirming parameter encourages a slight 'sit on your hands moment' and less rush.

It was even written that in an RTO due loss of thrust, the swing/yaw of the a/c was the 2nd parameter. Now I see guys being taught RTO based just on N1 gauges.
In this case, seat of pants g might have been the 2nd parameter. If the instrument is rolling & pitching, but you ain't spilling the coffee, it should cause a question. But are cadets, even old farts, taught this in the sim? I doubt it.

There are various scenarios where a 'it can't be happening' moment could occur. Remember the takeoff brief about RTO <80 & >80. There I was passing 100kts and the takeoff config horn sounded. 1st reaction was, "this should not be happening." I noticed a split flap gauge. 2nd reaction was "doubt, and when there's doubt there is no doubt, so we're better RTO-ing." It was home base, long enough runway. You could put it under the 'a/c unsafe to fly' category. It turned out to be a flap sensor that caused a split in the needles (not the flaps) and locked out the flap system. The point being there was a large ? floating around the flight deck for a couple of seconds.

[RAT 5]

Oh Dear! Really? Idle descent engine failure is a gotcha for that, but takeoff???

[Herod]

Standard brief in my old company: "Confirmed by two or more parameters"

[MurphyWasRight]

Would you immediately react accordingly (switch off AP, pull back on power, pull up nose - or whatever you do) or would you say "Oh balls! The fricken computer's on the fritz again!".

This suggests that one problem with current training is the (understandable) focus on situations that -do- require quick reaction such as failure at V1.

The 'muscle memory/quick action critical' learned though is likely carried over to more benign situations leading to immediate reaction rather than contemplation.

Combined with the high reliability of modern systems that diminish the "fricken computer's on the fritz again" thought since failures are rare and net result is what is being discussed on this thread.

[Livesinafield]

The testing is a bit of a joke these days anyway for LPC/OPC everyone knows what is happening and they know what is going to happen, V1 cut etc Single engine ILS RTO, all that rubbish.

Don't think i have ever come out of an LPC/OPC and actually learnt anything...just come out glad to have go through the "script"

Pre dep briefs are a total waste of time aswell "before 80 i will do this after 80 we will stop for this etc after V1 we carry on and this happens that happens...how about what happens if both PDF's switch off as you enter IMC at 500 feet ? But we never will talk about that because it will never happen.... because an engine failure exactly at V1 as it is taught will happen ?? right

[khorton]

Standard brief in my old company: "Confirmed by two or more parameters"

That is all well and good if you suspect a failure. But in this case no one suspected that the left attitude display had failed.

The attitude miscompute flags on the PFD on the CRJs are much less prominent than I would prefer. They are small amber boxes around amber text a bit offset from the centre of the PFDs. I'd prefer much larger text, right in the centre of the attitude display.

[_Phoenix]

I read the report, the essential sections. Something puzzles me
"In a normal seating position both right and left PFD could be seen from both left and right seat respectively without turning of the head."

"The analysis is therefore based on the assumption that the information displayed on PFD 1 was the same information as recorded by DFDR and that the information displayed on PFD 2 is consistent with the first 23 seconds of the simulation. This part of the simulation has been considered to have a very good conformity with the actual event."

http://www.mediafire.com/convkey/1cb1/dbh448qza382fdvzg.jpg

[Out Of Trim]

When the PFD 1 failed due to the data miscompare; why is the Autopilot designed to just auto disconnect straight away? If they programmed it to also pause and announce PFD or PITCH CROSSCHECK REQUIRED - without an auto disconnect then they would probably have been able to handle the failure easily and remained in straight and level flight.

Computers can detect mismatched data and compare all sources of that data extremely quickly, so why not use them to announce what has failed to improve situational awareness.

It seems to be that the immediate auto disconnect is what leads to instinctive pilot inputs, as nobody is now flying the aircraft. When no immediate action would be safer.

That may have saved this crew and indeed the AF.

[peekay4]

@_Phoenix

t0 is actually at 23:19:20 UTC (2 secs prior to transcript start)

At t15 the Copilot was probably looking at PFD2 and made the correct call.

But then at t17 the Captain pleaded "Help me, help me", so its possible that after this time the Copilot turned his head towards the the Captain and both were looking at PFD1. At t24 the Copilot may have looked back at PFD2 and uttered "No".

@Out Of Trim

The autopilot cannot determine what's being displayed to the pilots. The AP only knows that there were conflicting servo commands. When the AP disconnected, it left the aircraft in a stable, straight and level attitude.

[Intrance]

@Out of Trim:

Although that sounds like a plan initially, since the AP will follow FD1 when the LH pilot is PF, keeping the autopilot on will try to follow the FD1 anyway and still go nose down for example. If it switches to another mode like ALT or PTCH it could lead to more confusion ("why is it doing that"). A disconnect does not necessarily do anything to your flightpath. The plane is trimmed, power is set and very little variables change.

In the mean time, there will be at PIT flashing on the PFD and the EICAS should list EFIS COMP MON caution message. These two combined lead to a QRH checklist, which basically lists "compare EFIS and ISI, switch both PFD to output from the reliable data side (IRU2) and proceed with IRU failure procedure". Please note, this is paraphrase and I'm 700/900 rated, not 200. But I can't imagine there being much difference in the basic procedure.

This is also one of the things that surprised me. They should have had an EFIS COMP MON caution message which would have been a clear indicator to take a moment and cross check regardless of whether the PIT was visible or decluttered on the PFD. Cancel caution light, check EICAS, state the message displayed.

Easy in hindsight of course and we can read all the challenges the crew faced. It just seems like this is one that could have been so easily avoided which makes it extra sad and perplexing that it had this outcome.

[SE210]

Air France 447, Colgan 3407, Air Algerie 5017 (Swift Air), West Air 294.

Loss of control accidents happening in darkness - involving fatigue.

From my experience as an instructor and examiner, high altitude loss of control scenarios (particular in darkness) are critical. One thing that can not be simulated in the simulator is fear.

It is essential to avoid the fully loss of controls incidents, since the likelihood of recovery in my opinion is 50/50.

[alf5071h]

For those who wish to regress to hindsight, or ask why did't they..., I don't' understand..., etc, see the links to documents from Griffith University:-

http://www.icao.int/Meetings/LOCI/Presentations/Managing%20Startle%20Individual%20Crew%20and%20Organizationa l%20Strategies.pdf

Surprise - Startle
'... an appraisal that a situation is threatening and is beyond the immediate control of the individual'
'... significant impairment in information processing for up to 30 seconds.
... tasks such as attention, perception, situational awareness, problem solving and decision making can be markedly impacted. Communication is often disorganised and incoherent for some time'.

If this crew were severely startled, as is most likely, then none of what was recorded on the CVR and inferred to be communication may be relevant; similarly any inference of action from the FDR. These might be seen as illogical to us now (hindsight bias), but for some unexplained reason they may made sense to the crew at the time. What were those reasons; training, experience, safety promotions, ...
Also in this event there appears to be more than one opportunity for startle. Unexpected engine oil warning, stab trim and bank angle alerts, over speed warning; perhaps a never ending startle effect or at least multiple distractions as to where to direct attention.

Note the aspects in the presentation about 'Individual differences and defences, and organisational problems and strategies, which relate to the industry's problems noted in earlier posts.

http://www98.griffith.edu.au/dspace/bitstream/handle/10072/54072/82496_1.pdf?sequence=1

'... pilots have been surprised or startled by some event, and have as a result either taken no action, or alternatively have taken the wrong action, which has created an undesired aircraft state,
... have been far from optimal in their handling of unexpected events and rather than utilizing their skills, training and knowledge, have underperformed at exactly the time when these skills were most needed'.

Note the latter point, which relates to regulatory assumptions that the pilot will be able to manage such situations, yet research indicates that inherent limited human performance prevents this.

Training is a central issue, not that trainers are underperforming, but that operators are increasingly constrained by regulatory 'ticks in the box'.
Also relating to this are the delays in instigating change partly due to reactive safety management which requires 'evidence' from accident events. Because there are so few extremely rare events, and that each differ in nature, evidence is lacking. Also, if some events are judged on outcome (what happened,) then false patterns can be found - loss of control, which can result in inappropriate safety activity.
Alternative analysis, to the point of speculation, could identify patters which relate to 'why' the accident occurred, considering the contributions of man-machine-environment, such as surprise, alerting system design, certification process and regulatory assumption.
The accident report makes a good effort to move from 'what' to 'why', but falls down with the recommendations; more calls and communication, perhaps because 'startle' is not an engineering 'fact'.

There is little value in individuals, trainers, or operators beating themselves up in forums like this without safety leadership from the top, the regulators. But these organisations appear to out of step with reality of operations; deciding to use reactive safety and looking for 'evidence' from rare events. Evidence which might be found in everyday operations, the normality of operations, expectancy of success, training requirements, overly standardised procedures, and safety by regulation.
Or are the regulators to surprised to realise?

[PJ2]

alf5071h, thanks for your views, and the links on "startle".

[andrasz]

Excellent post alf5071h, many thanks!


One contributory cause not emphasised by the report but very significant is the fact that the failure happened during the landing brief, when effectively noone was flying the plane. The attention of both PF & PM were elsewhere, this amplified the startle factor.

[TowerDog]

Which is why we state during a brief: "You have the airplane".
Somebody is always supposed to be flying, nothing new, old rules.
We get paid well and have earned respect for being able to handle "startle" factors.
That is our job for :mad: sake.
Still not impressed.

[Capn Bloggs]

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

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

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

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

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

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

Towerdog: :=

[ATC Watcher]

alf5071h : excellent info . Thank you .

I wonder how many operators have implemented the upset recovery training package (UPRT) designed a few years ago with blessing of ICAO. There was a Notice of Proposed amendment by EASA to that effect in 2015 , but I do not think it is yet mandatory ( but stand to be corrected ).
An advanced version also contained the word ' COMPARE!" before taking any action on the controls If I remember.

Very appropriate here.

[RAT 5]

Which is why we state during a brief: "You have the airplane".
Somebody is always supposed to be flying, nothing new, old rules.

"Startle effect" has been mentioned.

IMHO if the former had been adopted the latter would not have happened. There would not have been any 'startle'. The PF, in tune with his instruments, would also have had a in tune 'seat if the pants' and there would have been a conflict of senses; and hopefully a WTF moment and a pause. This would have been true for both LHS & RHS. Easy to say from here, I know, but I think it might have prevented a rushed response. A good lesson to learn.

[Timmy Tomkins]

As ever a lot of useful comment on here. I have only flown one jet type with EFIS and liked it for mass info and ease of use but...it does take away the automatic scan that used to be the norm (and often disadvantage) of the old T panel and I feel that was a factor here.

I have had two ADI failures on conventionally instrumented aircraft and they were non events. It was instantly obvious what had happened without needing to think about it; even though one occurred in the first 500 feet of an IMC departure. The procedure to deal with it was also clearly understood - "ADI failure, you have control"and we carried on easily enough.

That the autopilot disconnected didn't help these guys either as they then used useful brain cells controling the a/c and sadly not in the best way but maybe the EFIS design was part of the reason why. The investigators seem to think so.

Bring back the scan as part of training procedures? Get into the habit of cross checking with the gyro standby during departure and approach for example, so that at least some form of cross checking becomes automatic.

[Olympia 463]

I am in awe of the knowledge and interpretation skills here. I think that the key thing to be learned out of all this is to always 'fly the aeroplane', but if you get so little time on the stick these days it may be impossible to keep up your skill. As a glider pilot (don't all laugh) and instructor (now retired) I was lucky, I made 2200 sorties and flew nearly 1000 hrs, every second of it hands on. Solly was a glider pilot too and you can see where that got him. Maybe compulsory gliding needs to added to the training syllabus. For glider pilots every landing is a CFIT.