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ILS27LEFT
5th Apr 2022, 16:13
Pilots of Air France #AF11 reported their Boeing 777 didn’t react to commands on final approach to Paris CDG

Skipness One Foxtrot
5th Apr 2022, 16:33
AF11 JFK-CDG opb F-GSQJ

https://www.airlive.net/breaking-pilots-of-air-france-af11-reported-their-boeing-777-didnt-react-to-commands-on-final-approach-to-paris-cdg/amp/

silverstrata
5th Apr 2022, 19:33
Finger trouble? Or computer trouble.
One of the two…..

Silver

Locked door
5th Apr 2022, 23:10
Sounds like simultaneous autopilot disconnect and over speed warnings.

The incident report will make interesting reading.

Recidivist
6th Apr 2022, 03:43
SLF here - could someone please enlighten me as to the significance of changing from 26L to 26R after the go-around? Thanks.
Edit: I Google Earth CDG and note that 26R is longer, so maybe the pilots just wanted more room to stop if needed, but the radio conversation mentions 27R which I assume is just a mistake?

BuzzBox
6th Apr 2022, 05:24
SLF here - could someone please enlighten me as to the significance of changing from 26L to 26R after the go-around? Thanks.
Edit: I Google Earth CDG and note that 26R is longer, so maybe the pilots just wanted more room to stop if needed, but the radio conversation mentions 27R which I assume is just a mistake?

Arrivals at CDG are normally conducted using the outer runways (ie 26L or 27R). In this case the first approach was flown to 26L and the aircraft eventually landed on 27R. The outer runways are the same length (2700m) and are shorter than the inner runways normally used for departures. The reports are all a bit vague about what happened, but my guess is they requested the second approach to 27R due to possible interference with the ILS signal on 26L.

FlightDetent
6th Apr 2022, 05:25
SLF here - could someone please enlighten me as to the significance of changing from 26L to 26R after the go-around? Thanks.
Edit: I Google Earth CDG and note that 26R is longer, so maybe the pilots just wanted more room to stop if needed, but the radio conversation mentions 27R which I assume is just a mistake?
More or less. The outer, shorter runways are used for landings normally. Having faced an issue with the flight controls or indications, picking a runway as long as possible to cater for the unforeseen is a prudent choice.

Depending on the nature of the trouble the subsequent review would probably pick it as a 'learning point' if they didn't. I mean, not an issue with Dash-8 or similat but for a T7 it's a no-brainer assuming the A/C capabilities were compromised.

CROSS-POSTED (edit) these guys landing on the outer anyway points nicely toward the case being just another day in the office.

SpamCanDriver
6th Apr 2022, 09:35
Sounds like simultaneous autopilot disconnect and over speed warnings.

The incident report will make interesting reading.

Same sound for the config warning when selecting landing flaps if the gear is not down on the 777 as well

N600JJ
6th Apr 2022, 11:11
CVR and FDR recordings under analysis at the French BEA

pmizrahi
6th Apr 2022, 14:08
Would they typically be flying an ILS or rather RNP approach ?

DingerX
6th Apr 2022, 14:23
"didn't react to commands" is a rather loose translation. I heard: "Problème de commande.... L'avion s'est auto-fait n'importe-quoi."
So, control problem. The plane went and did by itself n'importe-quoi.
n'importe-quoi is not always easy to translate into English. Literally it means "it does not matter what". In many cases, it can be rendered by bull****.

Here, it means that it decided to do something that had no apparent meaning and was not helpful, like, for example, turning off the glidepath and diving.

Check Airman
6th Apr 2022, 14:28
Thanks for the translation.

oceancrosser
6th Apr 2022, 14:42
"didn't react to commands" is a rather loose translation. I heard: "Problème de commande.... L'avion s'est auto-fait n'importe-quoi."
So, control problem. The plane went and did by itself n'importe-quoi.
n'importe-quoi is not always easy to translate into English. Literally it means "it does not matter what". In many cases, it can be rendered by bull****.

Here, it means that it decided to do something that had no apparent meaning and was not helpful, like, for example, turning off the glidepath and diving.

So in essence a: "What´s it doing now? Have you seen this before?" moment.

perceval
6th Apr 2022, 15:01
'probleme de controles de vol. L'avion a fait a peu pres n'importe quoi ' which I would translate : ' Flight controls problem. The Aeroplane was doing almost complete nonsense ' or maybe ' crazy stuff '. After the incident, the pilot requested vectoring for a long downwind 27R (which was eventually agreed upon by the controller) instead of coming back for 26L (Both outer runways). I suppose he wanted to be further away from inhabited areas to the south of CDG.

perceval
6th Apr 2022, 15:03
Typically the departing aircraft would have been on 26R while the landing traffic was on 26L . Standard configuration at CDG, which never interferes with ILS signals.

Capt Scribble
6th Apr 2022, 16:53
They were quite quick asking for a second approach. Although fuel would be a factor, after a serious loss of control, I might have prioritised some troubleshooting before another approach. Unless, of course, they suddenly twigged what happened.

physicus
7th Apr 2022, 07:44
To get back on topic - below is a brief analysis of the ADS-B data for said event. The only thing sticking out is the dropout of IAS messages. The likely cause however has nothing the do with the aircraft but is due to the receiver having provided that data dropping out (as in: aircraft flying behind obstacle as seen from receiver) and another receiver with poor signal strength has picked it up, but is missing many messages to include the not all too frequently sent BDS6,0 message containing IAS. See last plot of signal strength int he ADS-B feed.

In other words: A perfectly normal and stable looking ILS approach until lateral deviation followed by a goaround, to include a 4200fpm climb which of course would feel extreme as some pax have stated. Nice turn back on course and smooth intercept of goaround course exactly overhead the runway threshold.

https://cimg6.ibsrv.net/gimg/pprune.org-vbulletin/1000x1700/afr011_profile_c0d49ae635c307b05ec4c42bdd49a3226f04d008.png

alf5071h
7th Apr 2022, 13:51
Pilots control aircraft,

Crews command systems,

Which applies in this incident ?

Were there any changes between command and control or vice versa, when, why, how ?

eckhard
7th Apr 2022, 15:17
I think there is some confusion about the word, "commands", which AFAIK just means "controls" in an aeronautical context in French.
If I recall correctly, during the AF A330 stall accident in the Atlantic, one of the pilots said, "a moi les commandes" (or words to that effect), which translates to, "I have control" in English.

Some of the media seem to be translating the French word, "commande" into the English word, "command", whereas in this context "control" would be more appropriate.

Bellthorpe
7th Apr 2022, 16:16
I think there is some confusion about the word, "commands", which AFAIK just means "controls" in an aeronautical context in French.


That's correct. For example, 'the pilot at the controls' is 'le pilote aux commandes'.

212man
7th Apr 2022, 16:18
I'm assuming the translate to "guide us with tail wind" really means "turn/vector us downwind"?

alf5071h
7th Apr 2022, 17:56
Thank you ekhard et al; thus my translation is that a pilot (PF) has hands on stick and throttle, crew push buttons.

And for, and in-between these states the critical need to understand the situation, including the manoeuvring capabilities of manual and automatic aircraft control - in less than ideal circumstances.

‘Hands on’ adjustment requires a wide situational view - the map, even look outside, the big picture.
‘Button push’, linear, sequential, procedural adjustment via FMS and / or autoflight.

Which has the greater flexibility, the reactive capability in the situation - knowledge, experience.

glofish
7th Apr 2022, 17:58
I'm assuming the translate to "guide us with tail wind" really means "turn/vector us downwind"?
That is correct. Vent arrière means downwind in french.
I had written this earlier, before the "gentils modérateurs" censured the contribution .......

Capt Kremin
8th Apr 2022, 00:19
There was nothing wrong with the aircraft. The crew had the wrong runway/approach selected and tried to override the AP manually. The subsequent go-around was incorrectly handled in that they retracted the gear before the initial stage of flap, hence the config warning.

hans brinker
8th Apr 2022, 03:55
There was nothing wrong with the aircraft. The crew had the wrong runway/approach selected and tried to override the AP manually. The subsequent go-around was incorrectly handled in that they retracted the gear before the initial stage of flap, hence the config warning.

Source?..............

5star
8th Apr 2022, 05:35
There was nothing wrong with the aircraft. The crew had the wrong runway/approach selected and tried to override the AP manually. The subsequent go-around was incorrectly handled in that they retracted the gear before the initial stage of flap, hence the config warning.

oh dear Lord help us….
I thought we had seen it all at AF !
There used to be a very good video on Youtube about AF pilots.`The title (in French) translated into something like : ‘ Aaah at AF….where the pilots taught the birds how to fly…’.

Surely Boeing will come out with a report…
Been flying the Triple for nearly 20 years and have never seen or read this kind of behavior by the AP.
Imho it’s still IS one of the most reliable airplanes in the industry….

JPI33600
8th Apr 2022, 07:48
The crew had the wrong runway/approach selected and tried to override the AP manually.

This seems extremely unlikely. During its descent, the aircraft was (presumably under AP control) traveling east-west and aligned with runway 26L, which is the most southbound runway at CDG. Therefore, the left deviation from this initial trajectory, either AP- or human-commanded, puts the aircraft even more south of CDG, where there isn't any runway.

Would the crew had erroneously selected e.g. 26R instead of the desired 26L, your explanation could make sense (pilot trying to chase 26L manually at the very last moment), but then we would have seen an initial descent towards 26R, wouldn't we?

Care to explain your point in a more detailed fashion please?

josephfeatherweight
8th Apr 2022, 08:30
There was nothing wrong with the aircraft. The crew had the wrong runway/approach selected and tried to override the AP manually. The subsequent go-around was incorrectly handled in that they retracted the gear before the initial stage of flap, hence the config warning.
I imagine that Capt Kremin has taken a bit of a punt here based on the sounds in the background and I’m going to say, I reckon he is either correct or very close to it!

H Peacock
8th Apr 2022, 11:02
Was is not AF who tried to get a 777 airborne with the AP engaged on the ground? Heavy controls interpreted by the PF as a malfunction, so it resulted in a very high-speed abort! 🤔

Fursty Ferret
8th Apr 2022, 11:38
Therefore, the left deviation from this initial trajectory, either AP- or human-commanded, puts the aircraft even more south of CDG, where there isn't any runway.

If they were set up for the other runway, then it would go straight through the 26L localiser to the south without capturing. Then in the go-around it would turn sharply north to intercept the missed approach course.

I'd be sceptical but I've seen AF land a 777 after making a very similar mistake in the USA. We almost went around due to the subsequent airprox and were, frankly, astonished that the AF 777 continued to land from what we judged to be an extremely unstable position.

wheels up
8th Apr 2022, 15:14
Was is not AF who tried to get a 777 airborne with the AP engaged on the ground? Heavy controls interpreted by the PF as a malfunction, so it resulted in a very high-speed abort! 🤔

Air NZ at Narita. Engaged autopilot instead of auto throttle - changed logic after that incident so autopilot can’t be engaged on ground (doh!)

Dropp the Pilot
8th Apr 2022, 15:15
Captain Kremin's version is almost certainly correct because the embarrassed and flustered crew immediately darted back to the airport and landed. Maybe hoping nobody had noticed?

If they had genuinely thought they had a flight control problem they would have gone to a hold, done a flight control checklist as a precaution, and re-configured and re-calculated for a Flap 20 landing.

wheels up
8th Apr 2022, 15:18
Air France pilot error vs Boeing 777 technical failure - having spent 14 years flying the triple my money would be on pilot error.

Master warning is almost certainly the gear configuration warning, triggered when flap selected to landing position (F30 or F25) and landing gear not down and locked.

Propellerhead
8th Apr 2022, 15:27
Could be localizer interference, or even 5G? Wasn’t aware of France being affected by the 5G thing though. They may have asked for a different ILS as they didn’t trust the first one. Programming the wrong approach doesn’t make sense as they flew lined up to the correct runway until it veered off.

eckhard
8th Apr 2022, 15:41
Air NZ at Narita. Engaged autopilot instead of auto throttle - changed logic after that incident so autopilot can’t be engaged on ground (doh!)

I think AF also tried this at Lagos?

Locked door
8th Apr 2022, 16:59
I think AF also tried this at Lagos?


Yes they did. They rejected from above V1 and burst a lot of tyres.

suninmyeyes
8th Apr 2022, 19:45
Just a suggestion as I have seen a similar thing happen on a 777. One pilot is manually flying and the aircraft is on an intercept heading for the localiser. He asks the other pilot to arm the localiser. The P2 accidentally pushes the button next to it which is the autopilot engage button. The buttons are identical, small and square. The autopilot then engages and will maintain the same heading and descent rate and they will go through the localiser.

The pilot flying then thinks the controls have frozen. It is a busy time for the crew and there is a high workload. The warning you hear is the config warning which is probably because land flap was selected just before the gear had locked down. You then hear the autopilot disconnect warning which is at the point where things probably started to return to normal where the crew realised what had happened. I am not saying this is exactly what happened but from my experience and the noises it would be a plausible scenario.

I too think it is unlikely that there was a major control problem with the 777 and that is was more likely to be finger trouble. However we are all human and it would be wrong to specifically blame Air France. The autopilot engage buttons for both Captain and copilot, the autothrottle engage button and the localiser and approach buttons are all the same small square button. Yes on takeoff at Lagos the Air France crew accidentally pushed the autopilot engage button instead of the autothrottle button and thought the controls had jammed and rejected the takeoff bursting tires. They are not the only airline to have done that and Boeing have changed the logic to stop that particular error being made again.

Klauss
9th Apr 2022, 04:58
Could be localizer interference, or even 5G? Wasn’t aware of France being affected by the 5G thing though. They may have asked for a different ILS as they didn’t trust the first one. Programming the wrong approach doesn’t make sense as they flew lined up to the correct runway until it veered off.
Hi, I checked a website. Looks like there is mostly countryside under the 26L approach , at least where the deviaiton happened. Not much 5 G around there.

5star
9th Apr 2022, 05:23
Just a suggestion as I have seen a similar thing happen on a 777. One pilot is manually flying and the aircraft is on an intercept heading for the localiser. He asks the other pilot to arm the localiser. The P2 accidentally pushes the button next to it which is the autopilot engage button. The buttons are identical, small and square. The autopilot then engages and will maintain the same heading and descent rate and they will go through the localiser.

The pilot flying then thinks the controls have frozen. It is a busy time for the crew and there is a high workload. The warning you hear is the config warning which is probably because land flap was selected just before the gear had locked down. You then hear the autopilot disconnect warning which is at the point where things probably started to return to normal where the crew realised what had happened. I am not saying this is exactly what happened but from my experience and the noises it would be a plausible scenario.

I too think it is unlikely that there was a major control problem with the 777 and that is was more likely to be finger trouble. However we are all human and it would be wrong to specifically blame Air France. The autopilot engage buttons for both Captain and copilot, the autothrottle engage button and the localiser and approach buttons are all the same small square button. Yes on takeoff at Lagos the Air France crew accidentally pushed the autopilot engage button instead of the autothrottle button and thought the controls had jammed and rejected the takeoff bursting tires. They are not the only airline to have done that and Boeing have changed the logic to stop that particular error being made again.

suninyoureyes,

All very plausible, but since when are people not checking their FMAs any more? I just don‘t get it, especially on heavy jets where in reality you only end up after having learned the job and learned from mistakes one made on smaller jets. At AF it takes years to get onto the triple fleet….
And, as was said before, any control or flightcontrols problem would have lead to extensive checklist work after the missed, and that did not happen.
This event should be cleared up asap.

wheels up
9th Apr 2022, 06:45
Just a suggestion as I have seen a similar thing happen on a 777. One pilot is manually flying and the aircraft is on an intercept heading for the localiser. He asks the other pilot to arm the localiser. The P2 accidentally pushes the button next to it which is the autopilot engage button. The buttons are identical, small and square. The autopilot then engages and will maintain the same heading and descent rate and they will go through the localiser.

The pilot flying then thinks the controls have frozen. It is a busy time for the crew and there is a high workload. The warning you hear is the config warning which is probably because land flap was selected just before the gear had locked down. You then hear the autopilot disconnect warning which is at the point where things probably started to return to normal where the crew realised what had happened. I am not saying this is exactly what happened but from my experience and the noises it would be a plausible scenario.

I too think it is unlikely that there was a major control problem with the 777 and that is was more likely to be finger trouble. However we are all human and it would be wrong to specifically blame Air France. The autopilot engage buttons for both Captain and copilot, the autothrottle engage button and the localiser and approach buttons are all the same small square button. Yes on takeoff at Lagos the Air France crew accidentally pushed the autopilot engage button instead of the autothrottle button and thought the controls had jammed and rejected the takeoff bursting tires. They are not the only airline to have done that and Boeing have changed the logic to stop that particular error being made again.


I’ve always thought that this was an exceptionally poor piece of ergonomic design on the part of Boeing - the A/T switch, A/P switches and APP switch are identical and very close together - it has led to incidents in the past. When a conscious effort is made to differentiate other controls and switches (flaps, gear, strobes, landing lights etc.) what was Boeing thinking here?

In this incident looking at the graphs posted earlier, it appears that the LOC deviation occurred at exactly the same time that the vertical speed started increasing. I’m thinking that possibly the waypoints hadn’t sequenced, they went around due to unstable approach (gear not down? - master warning is definitely gear configuration warning) , and the aircraft attempted to turn back to the previous waypoint, hence the deviation. The deviation commences very close to 1000’ baro altitude - not sure what AF’s stabilised approach altitude is but 1000’ is typical, so this would fit in with that theory.

The only bulletins from Boeing re. 5G relate to interference with radio altimeters - there is no mention of the possibility of LOC interference, it’s most likely a different band altogether. LOC operates in the VHF band, 5G as far as I am aware operates predominately in the UHF band.
https://cimg8.ibsrv.net/gimg/pprune.org-vbulletin/1075x247/cb760fb8_a819_495b_a024_1f4208f42234_d0a77006d7f860b3c0cafd3 0d71d3f3a6e0f4894.jpeg

sorvad
9th Apr 2022, 07:03
Capt Kremin, Could you clarify what you mean by the wrong runway/approach selected? They called established on 26L and were cleared to land on 26L. There didn't seem to be any confusion from either the Crew or ATC as far as the runway was concerned, so I'm just wondering what sort of error you think they made?

wheels up
9th Apr 2022, 07:12
Looking at the YouTube video again I see that ATC instructed then to stop approach at 1500’ (1100’ AGL), and they were already having issues at that point.

But looking at the ADSB data it appears that the go around commenced (very close to 1000’ AGL) and THEN the deviation occurred.
https://cimg9.ibsrv.net/gimg/pprune.org-vbulletin/1942x1334/835c39e4_396e_44eb_9f17_fc6b35c33720_5ab1692943cbe7386d50c3d a807701a5d6333a0a.jpeg

airseb
9th Apr 2022, 07:42
Looking at the YouTube video again I see that ATC instructed then to stop approach at 1500’ (1100’ AGL), and they were already having issues at that point.

approach called a departing traffic from 26R to stop climb at 1500’. So no.

wheels up
9th Apr 2022, 07:48
approach called a departing traffic from 26R to stop climb at 1500’. So no.

Ah ok, it was for another AF aircraft - they do say stop approach though

Squawk_ident
9th Apr 2022, 08:09
Ah ok, it was for another AF aircraft - they do say stop approach though
Negative. It's a mistake in the translation. The controller issued a "stop climb at 1500 feet immediately" to the AFR HW. It was acknowledged by HW and partially blocked by the AFR 011 transmission.

wheels up
9th Apr 2022, 08:26
Thanks for clarifying,makes sense - captions on YouTube video incorrect.

Squawk_ident
9th Apr 2022, 10:50
Interesting article in the on-line "Airjournal"" yesterday 08APR. This article itself refers to another article from the French daily newspaper "La Tribune" which is unfortunately for subscribers only.

https://www.air-journal.fr/2022-04-08-air-france-777-les-pilotes-en-cause-5234978.html
I provide here-below a translation in English from an on-line translator though.

"
The first analyzes of the incident on Monday involving a Boeing 777-300ER from the airline Air France would show that the plane is not in question, the go-around not having been done according to the procedure, with the key confusion in the cockpit. Causing a reaction from the BEA, which recalls that the investigation is still ongoing.

The daily La Tribune explained on Thursday that it had had access to preliminary information sent by Boeing to the French national company, following the incident during flight AF011 on April 5, 2022, between New York-JFK airport and its base in Paris- CDG: the 777-300ER (F-GSQJ) was on final approach when the pilots reported a problem, performed a go-around before landing without any further problems. In an audio recording posted online, one of the pilots explained that the device “did almost anything”.

A version disputed by the daily, which cites 'several sources' having had access to the QAR (quick access recorder), recording for the aircraft manufacturer and the airline more or less the same data as the two 'black boxes' (FDR for flight data, CVR for cockpit conversations, access to which is reserved for investigators). This preliminary data would show that the 777 encountered “no flight control malfunctions”; Boeing reportedly told Air France that 'the reference aircraft responded appropriately to commands from the flight crew.'

This leads to the following assumption according to La Tribune: the pilots 'misinterpreted a situation and were not coordinated'. During the manual pilot descent, 'under a high stress factor after a tiring flight from New York and in difficult weather conditions', what could be a simple unstabilized approach would have been mishandled, 'with confusions on the distribution and performance of tasks. The daily cites in particular the TO/GA (take off-go around) switch which would have been activated four times.

Having opened an investigation for 'serious incident', the Bureau of Investigation and Analysis (BEA) reacted yesterday, via a message on social networks: 'Information published in the press: @BEA_Aero recalls that the flight data is still being analyzed / A communication will be made when we have a global understanding of the event”.

Remember that flight AF011 ended well and did not “close to crash” as heard elsewhere. And that each investigation leads to debates on the responsibility of the plane or the pilots, debates which end (in general) with the results of the investigation. Afterwards, it is sometimes up to the courts to sort it out, as in the case of Air France flight AF447…"

Jet Jockey A4
9th Apr 2022, 11:58
Interesting article in the on-line "Airjournal"" yesterday 08APR. This article itself refers to another article from the French daily newspaper "La Tribune" which is unfortunately for subscribers only.

https://www.air-journal.fr/2022-04-08-air-france-777-les-pilotes-en-cause-5234978.html
I provide here-below a translation in English from an on-line translator though.

"
The first analyzes of the incident on Monday involving a Boeing 777-300ER from the airline Air France would show that the plane is not in question, the go-around not having been done according to the procedure, with the key confusion in the cockpit. Causing a reaction from the BEA, which recalls that the investigation is still ongoing.

The daily La Tribune explained on Thursday that it had had access to preliminary information sent by Boeing to the French national company, following the incident during flight AF011 on April 5, 2022, between New York-JFK airport and its base in Paris- CDG: the 777-300ER (F-GSQJ) was on final approach when the pilots reported a problem, performed a go-around before landing without any further problems. In an audio recording posted online, one of the pilots explained that the device “did almost anything”.

A version disputed by the daily, which cites 'several sources' having had access to the QAR (quick access recorder), recording for the aircraft manufacturer and the airline more or less the same data as the two 'black boxes' (FDR for flight data, CVR for cockpit conversations, access to which is reserved for investigators). This preliminary data would show that the 777 encountered “no flight control malfunctions”; Boeing reportedly told Air France that 'the reference aircraft responded appropriately to commands from the flight crew.'

This leads to the following assumption according to La Tribune: the pilots 'misinterpreted a situation and were not coordinated'. During the manual pilot descent, 'under a high stress factor after a tiring flight from New York and in difficult weather conditions', what could be a simple unstabilized approach would have been mishandled, 'with confusions on the distribution and performance of tasks. The daily cites in particular the TO/GA (take off-go around) switch which would have been activated four times.

Having opened an investigation for 'serious incident', the Bureau of Investigation and Analysis (BEA) reacted yesterday, via a message on social networks: 'Information published in the press: @BEA_Aero recalls that the flight data is still being analyzed / A communication will be made when we have a global understanding of the event”.

Remember that flight AF011 ended well and did not “close to crash” as heard elsewhere. And that each investigation leads to debates on the responsibility of the plane or the pilots, debates which end (in general) with the results of the investigation. Afterwards, it is sometimes up to the courts to sort it out, as in the case of Air France flight AF447…"

Can you post the original French version please?

Squawk_ident
9th Apr 2022, 12:06
Can you post the original French version please?
The original link is at the top of my previous post...
Here again...
https://www.air-journal.fr/2022-04-08-air-france-777-les-pilotes-en-cause-5234978.html

Squawk_ident
9th Apr 2022, 12:45
The Youtube/Airlive link is truncated but is originally from Liveatc I presume. Here is the whole recording of the ATC from LFPG TOWER 120.900 for the appropriate 30 minutes window available from LiveATC.:120.9 is the TWR frequency for the south doublet. 119.25 for the north one.


https://archive.liveatc.net/lfpg/LFPG3-Twr-Apr-05-2022-0730Z.mp3
Please set the recording time at +18'35"/40" to have the whole uncut recording. Unfortunately AFR011 dialogue is in French but you almost have already the translation.
The dialogue with AFR HW is interesting because they did not reply to the first order to stop climb at 1500 at once. They apologised after because it was an "instruction flight"

meleagertoo
9th Apr 2022, 12:49
How many times, I wonder, has every Boeing pilot been told, "lis tes putains de FMA!" every time you make a mode change.
And when you do, how often does it instantly reveal the error of your ways?
Read your chuffing FMAs and "What's it doing now?" becomes redundant.

Sick
9th Apr 2022, 14:09
If pilots of a developing nation struggled to control perfectly serviceable airliners like AF seem to do, they would be banned from European airspace!

Hueymeister
9th Apr 2022, 14:28
Cognitive Incapacitation, correlation with French Bee 711?
https://youtu.be/LAtcrdJqJDc

Propellerhead
12th Apr 2022, 08:21
Confusion caused by the aircraft turning towards an active wpt behind them seems increasingly likely when they pressed toga.

wiggy
12th Apr 2022, 15:21
Confusion caused by the aircraft turning towards an active wpt behind them seems increasingly likely when they pressed toga.

I thought pressing TOGA on the T7 led to the aircraft maintaining whatever track it was following at the instant TOGA was pressed....
It's the next button press that might have caused problems/confusion in the past..

sorvad
12th Apr 2022, 15:42
LNAV automatically engages above 50ft on a normal Go around Wiggy.

zzz
12th Apr 2022, 15:50
LNAV automatically engages above 50ft on a normal Go around Wiggy.

Not on all the 777’s I’ve flown. If you hit the TOGA button you get THR TOGA TOGA as modes. LNAV has to be manually selected above 400’.
Air France 777’s might be in a different mod state however.

sorvad
12th Apr 2022, 16:01
Oh, my apologies to you Wiggy and zzz, I didn't know that. It does on all the 777's I've flown. Yes THR TOGA TOGA initially but the roll mode then automatically changes to LNAV without having to select it.

awair
12th Apr 2022, 16:43
LNAV above 50’ was a ‘block point’ upgrade. Not sure if it was optional/airline specific?

Dropp the Pilot
12th Apr 2022, 17:16
Confusion caused by the aircraft turning towards an active wpt behind them seems increasingly likely when they pressed toga.


Very common problem both in the sim and the real world and makes for an exceedingly untidy go-around.

If you are blessed to be 777 pilot, you have one sure fire defense: when the EGPWS calls "one thousand" during the approach, glance inside at the top right corner of the ND and ensure that the waypoint that is displayed there is a waypoint which is in front of you. If it is not a waypoint in front of you any go-around is going to be highly entertaining.

M.Mouse
12th Apr 2022, 17:30
For clarity LNAV automatic engagement following a go-around is an option but requires Aeroplane Information Management System (AIMS) 05.

It engages automatically following a go-around at 50'RA if the aircraft is manually flown or 200'RA if automatically flown.

sorvad
12th Apr 2022, 17:58
Thanks for the clarity regarding LNAV automatic engagement on the go-around folks. I wasn't aware it was anything other than standard on the 777. It certainly was a feature on the 200/300 and 300 ERs that I've flown. Interesting that it was an option as to be honest it could actually be a bit of a pain in the arse in the real Missed Approach world which was often 'climb straight ahead, maintain 3000' or something similar.

M.Mouse
12th Apr 2022, 22:43
Interesting that it was an option as to be honest it could actually be a bit of a pain in the arse in the real Missed Approach world which was often 'climb straight ahead, maintain 3000' or something similar.

In the Boeing 777 QRH section showing various manoeuvres for the go-around the procedure shows, at 400'RA, 'Select or verify roll mode'.

Arguments could be made for automatic or non-automatic LNAV engagement but in a perfect world at 400' the appropriate mode should be selected.

The problem arises, in my view, because most go-arounds often take the crew by surprise unless previously briefed for the possibility due to inclement weather. For this reason, and I see this regularly during conversion courses, go-arounds are generally well flown when expected and less well flown when a crew is taken by surprise.

When I was flying I clearly recall the startle effect when receiving an ATC instruction to go-around on a least two occasions when I least expected it!

BuzzBox
13th Apr 2022, 00:08
Thanks for the clarity regarding LNAV automatic engagement on the go-around folks. I wasn't aware it was anything other than standard on the 777. It certainly was a feature on the 200/300 and 300 ERs that I've flown. Interesting that it was an option as to be honest it could actually be a bit of a pain in the arse in the real Missed Approach world which was often 'climb straight ahead, maintain 3000' or something similar.

According to my files from that time, the automatic LNAV engagement on go-around feature could be activated as an option with the AIMS BP06 upgrade. The -300ERs operated by CX were delivered from 2007 onwards and came with the feature already activated. The -200 and -300 aircraft in the fleet were upgraded to the same standard ahead of the first -300ER delivery.

Smilin_Ed
13th Apr 2022, 22:09
"When I was flying I clearly recall the startle effect when receiving an ATC instruction to go-around on a least two occasions when I least expected it!"

"Startle" ??? Why would you be startled? Things happen and you should be ready to respond. Unless you are down to your last teacup of fuel, going around should not startle. Pilots are supposed to be cool and handle the situation.

BuzzBox
13th Apr 2022, 23:08
"When I was flying I clearly recall the startle effect when receiving an ATC instruction to go-around on a least two occasions when I least expected it!"

"Startle" ??? Why would you be startled? Things happen and you should be ready to respond. Unless you are down to your last teacup of fuel, going around should not startle. Pilots are supposed to be cool and handle the situation.

Easily said, but when something happens suddenly and unexpectedly, there will always be a moment or two before training kicks in, no matter how experienced the pilot. That's especially true at the end of a long overnight sector, when everyone's tired. It's also the time when pilots are most likely to make a mistake, particularly if the procedure has not been mentally rehearsed in advance. Pilots are human, not machines.

eckhard
14th Apr 2022, 08:36
Smilin Ed: Wow, you sound pretty cool. I must have missed the "don't get startled" module during my training. What's your secret?

Uplinker
14th Apr 2022, 09:58
I don't understand this incident because the pilots on the recording sound really stressed - breathing heavily, and not like a well trained professional crew calmly working through a problem.

CDG is not an easy airport at all - it is very complicated. However, during the briefing before TOD, the descent, approach, landing and go-around should have been discussed, programmed and checked. If, during the approach things went wrong and a go-around was required, there should have been no startle, just a reversion to plan B.

But Smilin Ed is right. Being startled means something unpredictable and unusual suddenly happens - like an engine fire or an explosive depressurisation for example. I don't know exactly what happened here but having to go-around from an approach should not be unexpected - especially at somewhere as busy and as traffic-dense as CDG. As pilots we are supposed to have a plan B in our minds, particularly during a busy phase involving a high workload.

If the aircraft suddenly banked when established on an ILS, my instinctive reaction would be to take out the autopilot and manually fly wings level, (or pull heading at least), "whoa there !", and track the localiser manually while we worked out what the problem was. If we could recover the approach, fine, but if we couldn't then we have already briefed the go-around.

Maybe they actually had a flight control problem and even manual control didn't work?

I am just an average Joe, FWIW, not trying to be clever.

Dropp the Pilot
14th Apr 2022, 15:33
'and even manual control didn't work?'

There is no manual control on the 777.

A couple of spoilers will function via cables and you can also crudely jerk the stab incrementally with cable inputs but Boeing says that these will "allow the pilot to fly straight and level until the electrical system is restarted."

Without electricity the airplane cannot be maneuvered.

zzz
14th Apr 2022, 17:51
From a well known Asian carrier who are not so busy at the moment

"Last week, there was a report of abnormal flight control behaviour on a B777 (not one of ours) arriving in Paris (CDG) while on final approach to land. A go-around was executed, and the aircraft returned for a normal approach and landing. Boeing have completed an initial review of the QAR data and found that the aircraft responded appropriately to the flight crew commands and that the associated warnings received were as expected. Boeing have not made any recommendations or specific actions at this time. Further information will be provided when the investigation is completed"

BuzzBox
15th Apr 2022, 03:11
If the aircraft suddenly banked when established on an ILS, my instinctive reaction would be to take out the autopilot and manually fly wings level, (or pull heading at least), "whoa there !", and track the localiser manually while we worked out what the problem was. If we could recover the approach, fine, but if we couldn't then we have already briefed the go-around..

As pilots, we like to think that we will react calmly to anything that comes our way and correctly follow the procedures. However, in the real world that does not always happen when something unexpected occurs, as I’m sure any simulator instructor/checker would attest. During my time as a trainer/checker, I saw a number of stuff-ups occur in the simulator in response to fairly simple failures at a critical time during an approach. The ‘startle’ effect is real and it can affect a crew’s performance immediately after an unexpected event, with potentially serious consequences.

The Effects of Startle on Pilots During Critical Events: A Case Study Analysis (https://research-repository.griffith.edu.au/bitstream/handle/10072/54072/82496_1.pdf)

Imagegear
15th Apr 2022, 07:02
I remember "Sully" had a few choice words to say about "startle effect"

IG

Uplinker
15th Apr 2022, 10:18
Yes an engine fire or an explosive decompression - or indeed, a sudden double engine failure - would certainly take a moment to assimilate !

I certainly took a moment to react the first time I practised spinning all those years ago during my ATPL training ! Even though I was supervised and did it deliberately and knew how to recover, it took a moment in an actual spin to assimilate the forward view and the sensations involved. But to me, being startled means rabbit frozen in the headlights, not knowing what to do next. Experienced airline pilots should hopefully be sufficiently practised in our drills that we are not 'startled' but revert to the appropriate memory drill or whatever.

But during an ILS, if the aircraft suddenly banked over, my first action would be to arrest that behaviour by taking control, and when I said manual control, sorry, I meant flying myself rather than using the ILS coupled mode; not mechanical reversion.

This crew were breathing heavily with their finger frozen on the PTT switch, which suggests they had a very severe control or engine problem, but apparently they didn't and landed normally soon after, without declaring an emergency.

If the 'startle effect' is a thing nowadays, then training needs to be adjusted to allow pilots more Sim practise in experiencing sudden unexpected serious events and performing their memory drills. But an ILS deviation or a failure to capture should not result in anyone breaking sweat.

BuzzBox
15th Apr 2022, 11:34
If the 'startle effect' is a thing nowadays, then training needs to be adjusted to allow pilots more Sim practise in experiencing sudden unexpected serious events and performing their memory drills.

On that, at least, we agree.

Managing Startle: Individual, Crew and Organizational Strategies (https://www.icao.int/Meetings/LOCI/Presentations/Managing%20Startle%20Individual%20Crew%20and%20Organizationa l%20Strategies.pdf)

Startle Effect Management (https://www.easa.europa.eu/downloads/67174/en)

Alrosa
15th Apr 2022, 13:54
In the end, it doesn’t really matter what anyone thinks regarding how pilots “should” react in a given situation; what matters is how they DID react; and why. If we don’t get to the bottom of that, it’ll happen again; I think we can all think of some well-known examples.

Similar incidents have affected experienced crews at most major airlines in the recent past, so maybe we need to re-evaluate our assumptions. We’d all like to think we could handle this but we’ve all also made stupid mistakes due to distraction, tiredness and so on.

Just some thoughts !

FullWings
15th Apr 2022, 20:56
I partially agree, but modern training now encompasses these sorts of things: distraction management, CRM, effective briefing, “caging the chimp”, and so on. Mode awareness is a biggie with heavily automated aeroplanes, and without prejudice to the upcoming incident report, is slated to have a role in the event under discussion?

Autopilot in and not doing what you want? Check to see that the programming is right: if you can fix it by pressing buttons in a reasonable timeframe without dramatic excursions from your desired flightpath then do it, otherwise get rid of it, correct manually and rebuild after. If you need to GA unexpectedly (should you always *expect* a GA...?), then unless it’s really close to the ground there should be time for a little mini-brief and some crew coordination?

Tiredness and unfamiliarity are holes in the cheese, but that’s all part of the game with LH operations, in that you need to ensure a safe operation when only at partial mental/physical capacity. A daylight return to your main base is at the opposite end of the spectrum, but that may cause problems with low arousal and over-familiarity (I think most of us have been there).

Luc Lion
19th Apr 2022, 11:13
Question from a private pilot (IR rated) not used to CDG ; between 18:50 and 20:10 in the VHF recording, there are 2 airplanes cleared to land in sequence on the same final segment for runway 26L.
At 17:50 Turkish 1NL is cleared to land runway 26L.
At 18:50 Air France 011 is cleared to land runway 26L while Turkish 1NL is 2 nm from touchdown (1 nm from touchdown at 19:26).
At 20:10 Air France RM is cleared to land runway 26L, 5 nm behind Air France 011.

Is it common at CDG to give a clearance to land while the preceding airplane is also cleared to land and on short final ?
I know that this is a common practice in the USA but I was in the belief that, in Europe, the clearance to land was only granted when the runway is vacated.

BuzzBox
19th Apr 2022, 11:53
Is it common at CDG to give a clearance to land while the preceding airplane is also cleared to land and on short final ?
I know that this is a common practice in the USA but I was in the belief that, in Europe, the clearance to land was only granted when the runway is vacated.

Except when low vis procedures are in force, ATC at CDG will grant a landing clearance on first contact with tower, based on 'anticipated separation'. Up to four aircraft can be issued with such a landing clearance. The tower then monitors visually and/or by radar to ensure the runway safety area is vacated by the preceding aircraft.

Luc Lion
19th Apr 2022, 12:06
Thanks.
I stand informed.

Chiefttp
19th Apr 2022, 13:07
The startle effect is real, I’ve witnessed a few instances of it. There are obviously different degrees of “startle” . Fortunately, in the last 7 years, my airline has been designing training scenarios to train for startle effect. For example, for years our V-1 cut was between V-1 and V-2, on the runway, now we get the engine failure airborne at different altitudes and configuration levels. One of the best scenarios is applicable to this event. It’s a go-around at altitudes from above missed approach altitude to 1000 ft AGL. It forces you to think about where you are in the approach regime and adjust automation as necessary.

DJ77
20th Apr 2022, 14:19
Meanwhile the subject T7 has remained grounded since the incident. There may be more than regular maintenance to perform in spite of initial statements that there was nothing wrong with it ?

Dropp the Pilot
20th Apr 2022, 15:02
A face-saving method for the crew and the airline.

After the aircraft arrived at the terminal It wouldn't have taken two minutes to download the FOQA and maintenance computer which will have shown there is nothing wrong with the airplane.

Check Airman
20th Apr 2022, 17:08
A face-saving method for the crew and the airline.

After the aircraft arrived at the terminal It wouldn't have taken two minutes to download the FOQA and maintenance computer which will have shown there is nothing wrong with the airplane.

Air France, having lost billions of dollars due to covid, has taken the plane out of service, and is sacrificing hundreds of thousands (or millions) of dollars in revenue, to save face?

am111
20th Apr 2022, 17:42
Air France, having lost billions of dollars due to covid, has taken the plane out of service, and is sacrificing hundreds of thousands (or millions) of dollars in revenue, to save face?

Depends on how busy the rest of AF’s fleet is. Aviation in Europe, whilst it is on the up it is still well down on pre-covid levels. If they’ve got AoG anyway, might as well make it one that is the subject of an investigation. Any other time, I’d agree with you though.

ATC Watcher
20th Apr 2022, 18:04
It would seem fatigue played a role there, from internal AF rumors on another site. not sure the BEA will go too deeply into that based on their past reports but who knows , maybe this time.

Uplinker
20th Apr 2022, 22:43
The startle effect is real.....

Yes, the startle effect is real - amongst the average human being. However, pilots should not suffer it, or should be trained out of it; That is part of what it is to be a pilot - you are not startled by events, but revert to a pre-programmed and pre-practised response to things that don't go according to plan. Isn't that what we practise and are selected and paid for ?

BoeingDriver99
20th Apr 2022, 23:34
The 'startle effect' is the industry term for amygdala or limbic hijack. In very simple terms we react to things in two broad ways:

1) Stimuli - senses - sensory cortex - amygdala - response. This is the cognitively engaged way; we are thinking about our reaction and it can be as low as 250 milliseconds for racing car drivers or professional athletes etc. But normally it's 500+ ms.

2) Stimuli - senses - - - - - - amygdala - response. This is amygdala hijack; it's reflexive and happens as quickly as 14 milliseconds. 14 ms!!! Too fast to stop or comprehend.

All mammals have this instinct and pilots are mammals. Some folk may be more resilient to amygdala hijack than others but this it not assessed directly at any point in pilot training/recruitment.

The problem is that this all occurs basically instantly HOWEVER the effect on cognitive performance can last for up to 60 seconds. Especially at a time when pilots are required to perform complex tasks with multiple stimuli - go-around with ATC instructions and conflicting traffic.

Also the research indicates that those who are highly proficient at a skill actually react better during amygdala hijack and those who are low in proficiency react even worse. So all the below average pilots who are probably less resilient to startle and don't mentally prime themselves well are affected even more than the average by 'startle'.

Also also; current training regimes can do almost nothing to really replicate real world startle effects. So in the sim you might see a pilot react poorly for a few seconds but fix it. And in real life you see what happens in this case....

Chronic Snoozer
20th Apr 2022, 23:36
Yes, the startle effect is real - amongst the average human being. However, pilots should not suffer it, or should be trained out of it; That is part of what it is to be a pilot - you are not startled by events, but revert to a pre-programmed and pre-practised response to things that don't go according to plan. Isn't that what we practise and are selected and paid for ?

Just because a pilot doesn't exhibit the symptoms of being startled doesn't mean they aren't, they've learnt to manage it. I think that's what you mean. By and large pilots are average human beings. Every generation wants to put their own spin (aka terminology) on what has been a fundamental concept in aviation since the Wright brothers - sh1t happens. It isn't a new concept.

43Inches
21st Apr 2022, 09:06
After the aircraft arrived at the terminal It wouldn't have taken two minutes to download the FOQA and maintenance computer which will have shown there is nothing wrong with the airplane.

And that is one of the worst case scenarios for fault finding an incident, the aircraft system not registering a fault, but a fault witnessed by multiple sources outside of the system, like the human component. That's when a plane will sit for long periods to work out the why and how.

ATC Watcher
21st Apr 2022, 10:21
And that is one of the worst case scenarios for fault finding an incident, the aircraft system not registering a fault, but a fault witnessed by multiple sources outside of the system, like the human component. That's when a plane will sit for long periods to work out the why and how.
Absolutely , if I remember correctly that was the case here : Martinair B767 Boston 1996 (https://aviation-safety.net/wikibase/147072)
Where it took quite some time to understand what happened.

Chiefttp
21st Apr 2022, 12:35
Yes, the startle effect is real - amongst the average human being. However, pilots should not suffer it, or should be trained out of it; That is part of what it is to be a pilot - you are not startled by events, but revert to a pre-programmed and pre-practised response to things that don't go according to plan. Isn't that what we practise and are selected and paid for ?

Uplinker,
I understand your sentiment. What I mean by “startle effect” isn’t a hysterical reaction to a situation, Instead, it’s when an event occurs outside of its “normal” or expected flight regime. For example, a go-around occurring at 1500 AGL as opposed to at decision Altitude where most pilots are expecting and thinking about executing a go-around. I’ve had two “aborted or discontinued approaches” which resulted in a go-around in the last few months. In both instances the F/O was flying. In both instances, the request by ATC took us by surprise and the go-around was not your typical scenario and some confusion ensued. In Seattle, flying into Boeing Field KBFI, you actually have to DESCEND while executing a “missed approach” or aborted approach due to crossing traffic ABOVE you approaching Sea-Tac Intl. Send 100 crews into a sim and give them that scenario and you’ll see many examples of “startled” crews.

DaveReidUK
21st Apr 2022, 12:50
A face-saving method for the crew and the airline.

After the aircraft arrived at the terminal It wouldn't have taken two minutes to download the FOQA and maintenance computer which will have shown there is nothing wrong with the airplane.

The aircraft in question is currently about an hour into an airtest CDG-CDG.

It may have nothing to do with the incident on its last flight, but on the other hand ...

Twiglet1
22nd Apr 2022, 06:02
It would seem fatigue played a role there, from internal AF rumors on another site. not sure the BEA will go too deeply into that based on their past reports but who knows , maybe this time.
Um JFK-CDG isn't exactly a long trip. Have the crew had a reduced roster due to AF coming out of Covid? Maybe its sleepiness (the need for sleep) rather than fatigue?

wiggy
22nd Apr 2022, 08:17
Well true the JFK - CDG sector won't have been a long one (by Long Haul standards) but what was the entirety of the trip flown by the crew?

I certainly recall occasionally feeling pretty sub-optimal on the final stages of many an eastern seaboard -LHR sector due to lack of sleep/length of time since any previous sleep....down to "sleepiness" or "fatigue"?

I know the vocab used matters to the regulator/operator ("but our rostering system means you can't be fatigued") but to those on the line does it really matter?

oceancrosser
22nd Apr 2022, 09:12
The aircraft in question is currently about an hour into an airtest CDG-CDG.

It may have nothing to do with the incident on its last flight, but on the other hand ...

Ok, thought it strange yesterday to see an AF 777 doing two subsequent go-arounds on 9R as we taxied out and held at the rwy. But this being a test flight crossed my mind.

Lord Bracken
22nd Apr 2022, 10:36
Ok, thought it strange yesterday to see an AF 777 doing two subsequent go-arounds on 9R as we taxied out and held at the rwy. But this being a test flight crossed my mind.

Were the BEA on board this "test flight?"

Uplinker
23rd Apr 2022, 04:34
Uplinker,
I understand your sentiment. What I mean by “startle effect” isn’t a hysterical reaction to a situation, Instead, it’s when an event occurs outside of its “normal” or expected flight regime. For example, a go-around occurring at 1500 AGL as opposed to at decision Altitude where most pilots are expecting and thinking about executing a go-around. I’ve had two “aborted or discontinued approaches” which resulted in a go-around in the last few months. In both instances the F/O was flying. In both instances, the request by ATC took us by surprise.............

Well, I don't want to make a big deal of this but all I can say is we must be using different dictionaries. In mine "startle" is "to be surprised or frightened, so as to start, [i.e. jump] involuntarily", (like someone suddenly shouting Boo! in your face).

While flying an airliner and having to do a go-around, or being told to do a go-around, that you have briefed and programmed for, does not startle me. Instead, I think, (in a bored tone of voice); 'oh bollocks, here we go'......"go-around flap" etc. I don't think 'oh **** !..........what.......what's happening?.............what the hell do I do now?', which would be more my definition of startle.

All approaches could be a go-around until you pull reversers on the runway. If an engine exploded, or there was an explosive decompression during the cruise; yes, we would all probably be a little startled initially, but then we would know what to do next.

If crews are being startled by a go-around, then frankly they are in the wrong job. Sorry.

aeo
23rd Apr 2022, 07:24
Missed approach:

From an aircraft perspective - Single push TOGA switches = leisurely 2000 fpm clb, (thr toga toga) if LNAV available it will auto engage at 50’ RA or above (thr lnav toga). VNAV is available at 400’ baro but whether or not you can use it is up to your company.

From a human perspective - What Uplinker said..

BTW, If you select toga at less than 2’ ra (when rollout is engaged) then nothing will happen so it’s manual thrust only …


// edited to add ra and baro.. . //

BraceBrace
23rd Apr 2022, 10:48
All reactions mentioning here determine startle "reaction" as controlled, however the main idea is that the physical reaction in a startle is "uncontrolled".

Whether "fight or flight" principles make you go-around or not, the action remains uncontrolled by the brain. Your body might be doing things, in a startle the brain is not moving along.

Those people thinking your go-around will be controlled are missing the point of the startle. You personally will only know if you go-around or not if you're experiencing it. And if you're experiencing it, the fact you go-around or not is not that important. The most important thing here is that apparently some people think they can control it. You can't. Live with it. Don't think you are different.

safetypee
23rd Apr 2022, 11:21
Uplinker # 97 :ok:

A safety issue in modern communication is in the use and intended meaning of words. Also, with some forms of training - define something, then that is what it is; no need to consider alternatives.

Surprise involves the unexpected; part of normal human activity which enables learning - ‘I didn't expect that’; thence evaluation, action, refection, experience. Surprise is within the process of awareness, and involves situational risk assessment and decision making; our reactions, activities align with the perceived risk.
As posted elsewhere, surprise can be ‘fundamental’, an exceptional situation which cannot be comprehended, unimaginable; a rare but not impossible situation.

Startle is generally accepted as an outward reaction, often physical, sometimes automatic depending on the extent of surprise.
Startle is often misused as something to avoid, like ‘error’, inappropriate action, judged after the fact.

In the 777 event or similar, crews might be surprised at the aircraft’s response to an activity.
No response to a manual input is surprising. Such situations require concentrated effort for evaluation and understanding, more often with time pressure.
A reaction (or not) to a button press or mode change might not be so surprising, even if not seen before or available from memory based on training or someone else's experience. A typical automatic reaction is to reverse the last action - backspace, undo, Ctl Alt Del, but even these should be done consciously.

Conscious activity is critical, this requires mental effort to change the mode of thinking; this is often lacking because of the surprise and demand for mental resource.

Training:
- “sit on your hands, count to four” this requires a change of thinking mode - slow down, a forced change to a conscious thinking mode.
- improving situational experience in simulation to develop agility and flexibility in situations without SOPs; unfortunately when surprised in our SOP dominated world, the activity is more often to search for an SOP (or something similar) before fully understanding the situation.

Some deeper / associated reading below; - also note the indications as to why CRM and monitoring might be less effective than we believe or rely on.
‘The Impact of Styles of Thinking and Cognitive Bias on How People Assess Risk and Make Real-World Decisions …’
https://www.spe.org/media/filer_public/ff/ca/ffcaafe4-6631-4092-ab98-3e9f2c2b220f/ogf_2016_11_pr_179197-pa.pdf

BuzzBox
23rd Apr 2022, 12:30
Missed approach:

From an aircraft perspective - Single push TOGA switches = leisurely 2000 fpm clb, (thr toga toga) if LNAV available it will auto engage at 50’ or above (thr lnav toga). VNAV is available at 400’ baro but whether or not you can use it is up to your company.

Sounds simple, doesn't it? Except there are a bunch of other steps in the procedure, including coordination with the PM. The initial part of the published Go-Around/Missed Approach Procedure for the B777 goes something like this (with slight variations between operators):

PF: Push the TO/GA switch, call "Go-around Flaps 20".
PM: Select the flap lever to 20.
PF/PM: Verify the rotation to go-around attitude and the thrust increases.
PM: Verify the thrust is sufficient/adjust as needed.
PM: Verify a positive rate of climb and call "Positive Climb".
PF: Verify a positive rate of climb and call "Gear Up".
PM: Select the landing gear to UP.
PF: Above 400 ft radio altitude, select or verify a roll mode.
PM: Verify the missed approach altitude is set.
PF/PM: Verify the missed approach route is tracked.
ETC...

You might argue that we practice those steps all the time in the sim and that pilots should be competent at doing them correctly, and I would agree. The problem, however, is that when something totally unexpected (eg a failure) occurs at a critical moment, most pilots are startled, if only momentarily. It's a completely normal human response. Most will recover reasonably quickly and fall back upon practiced routines such as the go-around procedure, but some pilots do not. They take longer to recover, their subsequent performance suffers and they get things wrong. It is not at all unusual to see pilots get the go-around sequence wrong, or to omit some steps altogether in such situations. I have seen pilots forget to select the flaps to 20 before selecting the gear up; forget to check the thrust is set; forget to check the correct missed approach altitude is set, forget to check the correct modes are annunciated. The list goes on and there are several relatively recent accident reports that document the inappropriate responses of crews when they were confronted with something unexpected.

vilas
23rd Apr 2022, 17:26
If crews are being startled by a go-around, then frankly they are in the wrong job. Sorry.
It will be considered anti pilot. These days any act of poor flying sends human factor specialists in a overdrive. Last year A350 on approach in Paris in good weather on approach as the PF disconnected the AP they got predictive WS warning. The crew of three was so surprised that they forgot the AP was off. Nobody flew the aircraft for next two minutes. Being Airbus it held the flight path (similar situation Kenya Airways B737 800 fatally crashed at Douala) slight bank taking it towards parallel RW and obviously busting MAA which low. ATC warned them and gave them heading to left which Capt the PM just dialed but Aircraft didn't turn. According to HF experts Startle or surprise caused cognitive failure. And that's the end of the story. All go home happily. But what happened to idea of take over if things don't happen the way you wanted. If PWS which is a thing you are not in but is ahead caused cognitive failure then a stall or fire warning would cause a heart attack. If you don't monitor speed on approach stall warning is always a surprise. HF has become a post mortem report and preserve of HF experts and investigators. In reality shouldn't active pilots have it's knowledge and be actively using it in their briefings according to situations as a safe guard against threats posed by them? Because human factors are nothing but human weaknesses which are likely to create errors.

FlightDetent
23rd Apr 2022, 19:04
That is pro-pilot, vilas. As long as we keep the terminology correct and know who a pilot is.

Captain obvious out.


​​​​​

airbow
24th Apr 2022, 02:57
The 777 involved in the incident has resumed normal commercial operations after its flight test a few days ago.

alf5071h
24th Apr 2022, 06:37
… Because human factors are nothing but human weaknesses which are likely to create errors.vilas, was this a question or a statement ?

Either way you will be surprised when realising the futility of the view, hopefully after a minor surprise; and not if but when.

Dropp the Pilot
24th Apr 2022, 14:44
The 777 involved in the incident has resumed normal commercial operations after its flight test a few days ago.

Nothing wrong with the airplane then, eh? The original pilots must be feeling pretty smug. They've known that for 19 days.

sorvad
24th Apr 2022, 18:47
Nothing wrong with the airplane then, eh? The original pilots must be feeling pretty smug. They've known that for 19 days.

I think you might want to look at the definition of smug. If the cap fits....

Uplinker
25th Apr 2022, 13:34
+1 vilas ! Great post.

I suspect what is probably really happening is that HR departments in airlines have decided it is their job to select pilots, and have taken over the selection process. So they put hopeful pilots through stupid tests which bear no relation to actually flying a big jet or dealing with problems on the ramp - tests such as 'what symbol should appear next', or 'who in a written passage about an office ordered which pizza', or 'what is the volume of this irregular solid' - answer in 20 seconds please !!! :mad:

The TREs are handed a group of people who passed these tests but have no time scheduled to properly check, so have to assume they are up to the job. Not necessarily so ! The trainees are told what to expect in the SIM, either by the training department of through each other via social media, so they can pass the tests.

Then, one dark horrible night on the line - or even a nice day - something happens that they have never thought about or experienced.............

Capn Bloggs
25th Apr 2022, 13:44
Uplinker, that's all well and good but you said on the previous page:
If crews are being startled by a go-around, then frankly they are in the wrong job. Sorry.
Exactly who's fault is it then, being able to be startled? You're quite happy to bash the pilots, when in fact it's got little to do with them. It's the system that has made them. Or are you suggesting that if you get startled by a no-notice go-around need then you should be sacked?

Smilin_Ed
25th Apr 2022, 14:19
Is a "startle" response to a go-around situation something that is caused by the company's aversion to additional flight time for financial reasons? Are pilots afraid of a go-around because they are afraid of arousing the wrath of the bean counters? Are they afraid of being being berated for delaying the schedule of the next flight?

Dropp the Pilot
25th Apr 2022, 14:32
No. No. and...... No


https://www.pprune.org/rumours-news/644277-lot-chocolates-going-around-2.html

Uplinker
25th Apr 2022, 14:55
Uplinker, that's all well and good but you said on the previous page:

Exactly who's fault is it then, being able to be startled? You're quite happy to bash the pilots, when in fact it's got little to do with them. It's the system that has made them. Or are you suggesting that if you get startled by a no-notice go-around need then you should be sacked?

No no; look, I am not 'happy' to 'bash' anyone I am trying to understand what is going on in aviation. Have you ever been startled, i.e. frightened into inaction, for something as simple and routine as a go-around? Here was a pilot so frozen that he gripped the yoke and held the PTT switch open for 20s and could be heard breathing heavily. And vilas tells us of another crew faced with a Windshear memory drill who did nothing for 2 minutes. And another pilot held full back-stick at FL 390 for an extended period and fatally stalled the aircraft.

I think pilots can be surprised but surely they should be able to swing into action; not be startled, frozen and scared - aren't we all selected and tested for our ability to be calm and know what to do in an emergency?
Maybe not any more. Are you really comfortable that some airliners are being piloted by apparently undertrained or poorly selected pilots, who cannot handle even a go-around : something every pilot should be expecting in the back of their mind all the way down the approach?

Better selection and training?

172_driver
25th Apr 2022, 19:01
Let me say it.. :E

More time with your hands on the stick and throttle, so when something unexpectedly happens you are one with the plane.
I am positive any hands on flight experience is positively transferred to other parts of flying. Being up to speed with your scanning and hand eye-coordination will make you better prepared for scenarios that unfold unexpectedly and requires timely action (such as a go-around from an odd state).

So in essence, better training required. And the right type of training.

CVividasku
26th Apr 2022, 08:01
No no; look, I am not 'happy' to 'bash' anyone I am trying to understand what is going on in aviation. Have you ever been startled, i.e. frightened into inaction, for something as simple and routine as a go-around? Here was a pilot so frozen that he gripped the yoke and held the PTT switch open for 20s and could be heard breathing heavily. And vilas tells us of another crew faced with a Windshear memory drill who did nothing for 2 minutes. And another pilot held full back-stick at FL 390 for an extended period and fatally stalled the aircraft.

I think pilots can be surprised but surely they should be able to swing into action; not be startled, frozen and scared - aren't we all selected and tested for our ability to be calm and know what to do in an emergency?
Maybe not any more. Are you really comfortable that some airliners are being piloted by apparently undertrained or poorly selected pilots, who cannot handle even a go-around : something every pilot should be expecting in the back of their mind all the way down the approach?

Better selection and training?
If you're criticising pilot's selection, then you should know that the captain of this flight had at least 20 years of airline experience, and the copilot we can't know for sure but several years at least (a grand minimum of 4, most likely between 6 and 14), so the problem would date back to many years ago.
Were you already criticising pilots selection 20 years ago ?

I'm seeing you joined the forum more than 20 years ago, so you could just read your own old posts to figure that out ! (I won't do it though, these posts belong to you)
So in essence, better training required.
I fully agree with the hands flying part (which should still be discussed on another topic), but you can't train that in training "per-se". You're not going to pay the big bucks for a full crew and a sim with no passengers.
You learn to fly with a sim, but then you practise on the line.

An intermediate solution that I would like to see for myself would be if airlines developped an easy to install at-home sim, based on a VR headset or at-home screen, company provided joysticks and thrust levers, and you could just practise your basic hand flying with it. It wouldn't be quite the same but the cost would be minimal and I'm sure it would be of some help. The visual circuit is the same whether it's a sim or an airplane.

BoeingDriver99
26th Apr 2022, 08:43
Physical responses to startle effect/amygdala hijack include increased eye blinking, deeper breathing and/or a jerk away from the threat. If a pilot had something unusual/surprising happen AND DIDN’T blink or take a deeper breath then I’d be veryyyy surprised. It’s a normal and natural human response and all mammals do some variation of it. If you don’t then you deviate from the norm. Would be fun to run some experiments on you!

ATC Watcher
26th Apr 2022, 10:36
You really cannot really "train" adequately to combat the "Startle effect" and as explained earlier ,it would be very expensive , but there is another level often following surprise , is "fear" , fear induced by not immediately understanding what is happening , which can be followed by "the tunnel vison" and going for the wrong solution . , examples : 3 miles islands or AF447 ..This last process has been studied and is well explained in Charles Perrow books, if you have time to spare I recommend to read his first one : "Normal accidents".
Everyone tend to think he can be superman and able to cope with every situation , but ,as Boeingdriver99 just said, we are mammals there are natural responses one cannot suppress .Some are better than others at it, it depends also in you state of mind ,level of fatigue/lack of sleep. circadian clock you are in ,etc..,
In an emergency situation have seen some very good controllers "freeze" then fear made them act irrationally. The good thing about ATC is that the people do not die and can be debriefed. In this particular case , as both pilots survived, a debrief with a trained human factor specialist.
might help understanding the why . But if the rumors are correct I doubt however it will be made public.

Uplinker
26th Apr 2022, 11:58
I have never claimed that I am Chuck Yeager or Neil Armstrong, or even the ace of the base and certainly not Superman - far from it. I am just an average pilot (and am not claiming that I have a perfect flying record either !).

But I am confused that in recent years we have had:
A crash at SFO because nobody did anything about the speed dying away.
A crew with mode confusion who stayed on the runway well past Vrotate and then flew very very low, barely missing buildings, instead of climbing away.
A pilot who held full backstick at FL390, fatally stalling the aircraft.
A crew who forgot to select TOGA when trying to fly a baulked landing.
A crew who continued when they were so hot and high, they forgot to lower the gear, scraped the engines along the runway, got airborne again and fatally crashed.
A crew who landed so fast and deep that they went off the end of the runway.
A crew who after landing tried to use the yoke as a steering wheel to stay on the centre-line instead of the rudder, during a crosswind landing, and went off the side of the runway.

All of the above were basic piloting errors and none of the above were owing to engine fires or control problems and were not difficult or complicated problems. But if I and my colleagues had done any of these things in our initial airline Sim test, we would not have been employed by the airline - it would have been "thanks, but PFO".

The last real piloting events I can think of were the B777 into EGLL with double engine failure at very short finals owing to blocked fuel filters - saved by the quick thinking of the crew who raised the flaps one stage and just managed to get over the fence. Another was the QANTAS A380 with an exploded engine and dozens of ECAM warnings. And of course the Cactus double engine failure, landing on the Hudson river. All fantastic piloting and surely what we expect from pilots, (and would hope to achieve ourselves), are they not?

So I am honestly not bashing pilots as such; but just wondering what is happening to aviation? We now hear about this startle effect, which now seems to be used as an excuse when pilots make basic flying mistakes. Are we not selected as pilots exactly because we can deal with problems in a calm and controlled manner? How are some pilots now getting so badly out of shape with standard flying and standard manoeuvres? Is it the training or the selection or something else?

alf5071h
26th Apr 2022, 14:42
Understanding incidents and accidents can be biased by the initial framing.
Statements using ‘crews’, ‘pilot’, ‘they’, are more likely to be interpreted as ‘pilot bashing’, human factors at the sharp end, opposed to considering alternative contributing factors

From the examples above:-
Weak auto thrust design, the system could go to sleep; the designer was surprised.
Weak FD switching logic, mandated use of FD for takeoff; the operator was surprised.
Multiple probe icing beyond the conditions assumed by regulation; the regulator was surprised

In these events and others, the expectation (after the fact) is that the human should have managed the system deficiencies. Our, operational expectations are influenced by hindsight, whereas design and regulation have to anticipate.
The expectation is that humans will manage malfunctions in those systems which were fitted to ease workload, minimising ambiguity, to provide a higher level of safety than the human alone was capable of.
Catch 22: After recognising human limits, additional safeguards were provided; however these required the human to manage failures in the same systems designed to overcome human limitations.

The industry has a high level of safety, such that accidents have few if any common factors, except the human; thus inappropriate focus on the human. It is time for safety management to appreciate uncertainty in operations and its effect on human performance; don't start with the human, consider the overall system.

Smilin_Ed
26th Apr 2022, 22:25
Uplinker: Everything you list is simply a failure of the person at the controls to fly the airplane. No procedures can substitute for that.

1. Aviate (Fly the airplane.)
2. Navigate
3. Communicate

If you don't do number one, you won't get a chance to do the others.

Big Pistons Forever
26th Apr 2022, 22:31
You really cannot really "train" adequately to combat the "Startle effect" and as explained earlier ,it would be very expensive .

You absolutely can set up a startle effect scenario for the crew to work through, a hugely beneficial exercise. However airline executives want the cheapest training possible. That is why most sim training is a box ticking exercise designed to meet the exact minimum proscribed regulatory requirements. Putting in some free form training exercises so pilots can stretch themselves cost money, that is why it doesn’t happen.

H Peacock
26th Apr 2022, 22:57
From the examples above:-
Weak auto thrust design, the system could go to sleep; the designer was surprised.
Weak FD switching logic, mandated use of FD for takeoff; the operator was surprised.
Multiple probe icing beyond the conditions assumed by regulation; the regulator was surprised

Okay, the above anomalies occurred, but the in each case the aircrew made some woeful errors that actually caused the accident/incident:
- No attempt to monitor the airspeed during the approach into SFO
- Blindly following the FD during take-off without looking out of the window (or again, monitoring their airspeed!)
- Continuing to maintain a pitch-up input despite the obvious clues!

alf5071h
27th Apr 2022, 07:52
The adverse human view continues, ‘aircrew’, … ‘error’ - a definition after the fact.
Similarly human activities, ‘monitor’, ‘blindly following’, ‘continuing to maintain’, describe what is assumed to have occurred, but for which we have insufficient knowledge about the crews were thinking, nor their reasoning of the choice of activity / inactivity.

The important question is if it is reasonable to expect crews to manage these situations, considering the nature or rarity of the anomaly, the operational pressures, and crew’s training and experience.
40 yrs ago safety was defined by outcome, body count. Nowadays, still based on outcome, much safer, but we fret over mistaken button pushes, the finesse of flight control and judgement calls, in very safe but vastly more complicated aircraft flown in complex situations.

This incident had a safe outcome; how was that accomplished, compare that activity with the vast number of normal operations. Then and only then consider the specific activities which we judge adverse, what is assumed, taken for granted.
The investigation into this event could help with these questions, but even so, our biased selves with hindsight will conclude what ever we wish; what we choose to learn.

Lord Bracken
27th Apr 2022, 17:22
The BEA have issued a report

https://twitter.com/bea_aero/status/1519358975141203968?s=21&t=d9GvGl56EXgtT73k2agEIg

Intrance
27th Apr 2022, 18:31
So if I am reading this right, the copilot was surprised by his actions having the exact consequences you'd expect, given this collection of input/output data? Eg. mostly left roll input, airplane banks left.
Or did he maybe expect higher roll rate from the aircraft for his inputs? I know this is just a preliminary report/investigation update, but seems like there was not much wrong with the aircraft.

About the fact that they did not notice their conflicting inputs... I do not fly the type, so excuse my lack of knowledge on the exact flight control config on the 777. But is it not supposed to be one of the upsides of Boeings FBW philosophy, to keep the yokes still moving in sync and provide feedback?

Dropp the Pilot
27th Apr 2022, 19:53
So....nothing wrong with the airplane other than that the two people sitting farthest forward were not competent and disciplined pilots.

Quelle surprise.

tdracer
27th Apr 2022, 20:14
About the fact that they did not notice their conflicting inputs... I do not fly the type, so excuse my lack of knowledge on the exact flight control config on the 777. But is it not supposed to be one of the upsides of Boeings FBW philosophy, to keep the yokes still moving in sync and provide feedback?
Yes, the control wheels are physically interconnected so that whatever one wheel does, the other does.
There is a 'breakout' feature that can disconnect the two should one get jammed, but it takes considerable force to trigger that 'breakout' and it certainly doesn't look like it came into play in this incident.

zzz
27th Apr 2022, 20:47
It seems like both pilots made control inputs simultaneously but there doesn’t sound like a break out of the control columns happened; that requires a lot of force.
Why was the FO confused about the bank? He was hand flying in cloud. Did he become disorientated and/or have “the leans”?

FlightDetent
27th Apr 2022, 20:47
The BEA press release clearly spells the flight column channels had been temporarily de-synchronized due to opposing forces on the yoke. := Also, note "8" explains what that means and the 50 lbs force required. Parlez vous Twitter?

How that works or manifests IRL would be great to hear if someone has the knowledge or experience to share.

beardy
27th Apr 2022, 21:18
FFS "I have control" end of. But then the French have an inordinate love of the third person indefinite.
On est un con.

Intrance
27th Apr 2022, 22:54
Yes, the control wheels are physically interconnected so that whatever one wheel does, the other does.
There is a 'breakout' feature that can disconnect the two should one get jammed, but it takes considerable force to trigger that 'breakout' and it certainly doesn't look like it came into play in this incident.

OK, that is what I expected. Slightly odd to not have noticed those 'de-sync' or breakout moments, though I can see it possibly being missed or forgotten about in a high stress/high workload situation. And it kind of seems like the pilot flying caused such a situation with the pilot monitoring trying to understand what was going on and failing to intervene properly.

I think this investigation and its results will be pretty interesting reading, though possibly not very flattering for the pilots...

tdracer
27th Apr 2022, 23:36
The BEA press release clearly spells the flight column channels had been temporarily de-synchronized due to opposing forces on the yoke. := Also, note "8" explains what that means and the 50 lbs force required. Parlez vous Twitter?


If they activated the breakout (surprising - the normal loads on the 777 control wheels are pretty light as long as you're not doing something stupid like pulling into a stall - to have to apply greater than 50 lbs. on the wheel should have been a dead giveaway that the pilots were working against each other), I'm reasonably sure it takes a maintenance action to reconnect them (I'm thinking it's a frangible link but I'm not sure about that). So that would explain the aircraft being grounded for a few days after the event.

am111
28th Apr 2022, 00:51
Ignoring the initial confusion and left roll by the PF. Seems like the pilots conception of the aircraft not responding to commands as expected could be due to them fighting each other without realising it and believing they are fighting the aircraft? They then apply this mental model retroactively to the initial event?

BuzzBox
28th Apr 2022, 02:53
If they activated the breakout (surprising - the normal loads on the 777 control wheels are pretty light as long as you're not doing something stupid like pulling into a stall - to have to apply greater than 50 lbs. on the wheel should have been a dead giveaway that the pilots were working against each other), I'm reasonably sure it takes a maintenance action to reconnect them (I'm thinking it's a frangible link but I'm not sure about that). So that would explain the aircraft being grounded for a few days after the event.

The control column breakout mechanism is a cam and roller mechanism, held together by springs. The flight parameters in the report show the control columns were ‘desynchronised’ for about 15 seconds. After that, they again moved in unison. The control wheel jam breakout mechanism has two force limiters and two lost motion devices that allow the other control wheel to continue roll control if one of the control wheels jams. The flight parameters show the control wheels were desynchronised for two brief periods of 2 seconds and 5 seconds duration during the same period the control columns were desynchronised.

The force required to override either breakout mechanism is 50 lb.

runner1021
28th Apr 2022, 03:50
Yet another wrestling match at AF.

Perhaps it"s their actual procedure ..... best man wins. :ugh:

ATC Watcher
28th Apr 2022, 05:27
Yet another wrestling match at AF.
Perhaps it"s their actual procedure ..... best man wins. :ugh:
Good one :ok:, Indeed not a good day for them again. The BEA does not make any remark on the rest / fatigue status of the pilots which is one of the main rumors around CDG . But that might come with the full report, although, based on their previous publications, I am not sure the BEA will go too deeply into it..

BuzzBox
28th Apr 2022, 05:52
Good one :ok:, Indeed not a good day for them again. The BEA does not make any remark on the rest / fatigue status of the pilots which is one of the main rumors around CDG . But that might come with the full report, although, based on their previous publications, I am not sure the BEA will go too deeply into it..

Recency is another factor they should consider, given the reduced flying rate for most pilots during COVID.

FlightDetent
28th Apr 2022, 10:28
The control columns were ‘desynchronised’ for about 15 seconds. After that, they again moved in unison.And desynchronised twice again momentarily. Revealing 50 lbs of opposing force - unless the mechanism was misadjusted soft (speculation, don't even know how it works) and uncoupled too easily.

The idea that on a Boeing you can't feel with your steering what the other person is doing or overpower him is a novelty in many circles, mine included.

​​​​

FlightDetent
28th Apr 2022, 10:30
https://cimg8.ibsrv.net/gimg/pprune.org-vbulletin/800x400/1651141851_c0779fbd71bd40ffd4f8cb4b5165c2a68257cb52.jpeg

Maninthebar
28th Apr 2022, 11:17
It appears that the BEA are just as puzzled by
a) desynchronised control inputs and
b) the inability of the crew to recognise them
as this forum is.

Twiglet1
28th Apr 2022, 11:34
Recency is another factor they should consider, given the reduced flying rate for most pilots during COVID.
So recency is an issue and ATC watcher is saying fatigue played a hand. If its recency then its sleepiness (the need for sleep) rather than fatigue. There is a subtle difference ATC Watcher

ECENE
28th Apr 2022, 11:41
Thinking about some of the earlier mentioned incidents:
does anyone believe that a competent pilot might be more concerned about complying with FDM readings rather than physics or his own pilot’s knowledge?

BuzzBox
28th Apr 2022, 12:03
And desynchronised twice again momentarily. Revealing 50 lbs of opposing force - unless the mechanism was misadjusted soft (speculation, don't even know how it works) and uncoupled too easily.​​​​

Thanks - The flight parameters show the control columns (ie pitch control) were desynchronised for 14 seconds from 07:51:16 until 07:51:30. The control wheels (ie roll control) were desynchronised for two brief periods during the same time period (07:51:16 - 07:51:18 and 07:51:23 - 07:51:28). Updated above.

Denti
28th Apr 2022, 12:46
The idea that on a Boeing you can't feel with your steering what the other person is doing or overpower him is a novelty in many circles, mine included.
​​​​
Indeed, that is puzzling. Might there be a need for a dual input aural warning after all?

FlightDetent
28th Apr 2022, 15:44
On a second thought, you have tacile feedback and actually you can feel what he is doing exactly with 50 lbs of force.

​​​Enough for a pilot to notice.

Is it me or does the reaction to the initial confusing bank, by additive increasing inputs, sound like spatial disorientation and reading his PFD in the opposite sense by the PF?

Is so the puzzles observed all fall into place.
​​​​​​

Fursty Ferret
28th Apr 2022, 16:53
Revealing 50 lbs of opposing force - unless the mechanism was misadjusted soft (speculation, don't even know how it works) and uncoupled too easily.

The 777/787 actually sense torque directly on the control columns and wheels.

tdracer
28th Apr 2022, 17:48
The control column breakout mechanism is a cam and roller mechanism, held together by springs. The flight parameters in the report show the control columns were ‘desynchronised’ for about 15 seconds. After that, they again moved in unison. The control wheel jam breakout mechanism has two force limiters and two lost motion devices that allow the other control wheel to continue roll control if one of the control wheels jams. The flight parameters show the control wheels were desynchronised for two brief periods of 2 seconds and 5 seconds duration during the same period the control columns were desynchronised.

The force required to override either breakout mechanism is 50 lb.
OK, I stand corrected - that's different than some of the older Boeing aircraft.

Rozy1
28th Apr 2022, 20:05
On a second thought, you have tacile feedback and actually you can feel what he is doing exactly with 50 lbs of force.

​​​Enough for a pilot to notice.

Is it me or does the reaction to the initial confusing bank, by additive increasing inputs, sound like spatial disorientation and reading his PFD in the opposite sense by the PF?

Is so the puzzles observed all fall into place.
​​​​​​

Are AF pilots unable to understand blue sky/ brown ground and the presentation of the aircraft’s attitude on their instruments? Is that what you’re implying?

Does AF have procedures for transfer of control. At my airline, one pilot is the PF, one the PM. Anytime the PF for whatever reason takes control, that person states (out loud) “I have the aircraft “. Then the PF responds with “You have the aircraft.” No confusion, no fighting.

CVividasku
28th Apr 2022, 20:22
Are AF pilots unable to understand blue sky/ brown ground and the presentation of the aircraft’s attitude on their instruments? Is that what you’re implying?

Does AF have procedures for transfer of control. At my airline, one pilot is the PF, one the PM. Anytime the PF for whatever reason takes control, that person states (out loud) “I have the aircraft “. Then the PF responds with “You have the aircraft.” No confusion, no fighting.
If both pilots believe the aircraft is going in the wrong direction (with only one being right about the direction), both are going to take action because they both believe (with only one being right) that the aircraft is in a bad position, and one golden rule is "if things don't go as expected, take action"

For your first point, spatial disorientation can happen, it has happened before to pilots from all over the world, it will probably happen again.
Maybe standardizing the attitude indicator would avoid a fraction of these disorientations.

VinceR
28th Apr 2022, 21:57
If both pilots believe the aircraft is going in the wrong direction (with only one being right about the direction), both are going to take action because they both believe (with only one being right) that the aircraft is in a bad position, and one golden rule is "if things don't go as expected, take action"

And the way to do that is :
1) Say clearly "I have control"
2) Take control

If you jump to point 2), it is going to be messy.

Latestormer
29th Apr 2022, 02:09
At some stage this industry decided to sell cheap tickets and become really competitive.

My understanding is that we can't have all we want at the same time. Top tier (not talking about flight hours) pilots will take a good screening process to hire and a nice syllabus to qualify them. And that's to begin with... But the industry demand cheap tickets.

If a normal G/A scares a Capt to the point he quietly pushes the control column thinking 15° pitch is just too much, I'd pay tickets to watch his previous checkrides and carefully listen to what it's like flying with him.

...And that's from someone who has already seen 10,000h+ "captainS" crashing on the simulator (and being approved on their recurrent lately).

BuzzBox
29th Apr 2022, 04:39
If a normal G/A scares a Capt to the point he quietly pushes the control column thinking 15° pitch is just too much, I'd pay tickets to watch his previous checkrides and carefully listen to what it's like flying with him.

I doubt that's the case here. The flight parameters show the pitch was stabilised at just under 15° during the initial go-around and stayed there for several seconds. The FO then started moving the control column aft. The Capt almost immediately opposed the rearward movement, presumably with sufficient force to desynchronise the control columns. At that point, the control column on the FO's side kept moving aft, while the control column on the Capt's side moved forward. The net result was an increase in the pitch attitude to 24°.

The question is: Having established the go-around attitude, why did the FO then start trying to raise the nose further?

ATC Watcher
29th Apr 2022, 04:44
Latestormer : pilots will take a good screening process to hire and a nice syllabus to qualify them. And that's to begin with...
Quite agree with your post , except here we are not talking about a low cost/ low pay/ cheap airline, quite the contrary in fact .
Would be interesting to read later the age/experience gradient between the two. Although AF, as far as I know, does no normally put 250h cadets on their 777, they sometimes put 2 captains.

ATC Watcher
29th Apr 2022, 04:52
So recency is an issue and ATC watcher is saying fatigue played a hand. If its recency then its sleepiness (the need for sleep) rather than fatigue. There is a subtle difference ATC Watcher
Just to be clear : I did not say this was the case, just reporting the rumor I heard, I am aware of the subtle difference between sleepiness and fatigue, but I am using here in purpose the generic term "fatigue" to describe the rumor I heard.

Latestormer
29th Apr 2022, 07:10
I doubt that's the case here. The flight parameters show the pitch was stabilised at just under 15° during the initial go-around and stayed there for several seconds. The FO then started moving the control column aft. The Capt almost immediately opposed the rearward movement, presumably with sufficient force to desynchronise the control columns. At that point, the control column on the FO's side kept moving aft, while the control column on the Capt's side moved forward. The net result was an increase in the pitch attitude to 24°.

The question is: Having established the go-around attitude, why did the FO then start trying to raise the nose further?

I don't see it that way. FO was the PF. CA should never touch the controls without announcing it (but probably veeery used to do things like that, most likely doing that for years, until he almost killed everybody). Also, you're biased thinking that it was the captain counter-reacting the FO input. Somone could clearly state the other way around since these events happened simultaneously. I'd say that we have another somatogravic illusion case here. But let's wait for what BEA has to say.

Quite agree with your post , except here we are not talking about a low cost/ low pay/ cheap airline, quite the contrary in fact .
Would be interesting to read later the age/experience gradient between the two. Although AF, as far as I know, does no normally put 250h cadets on their 777, they sometimes put 2 captains.

The whole industry became low cost. First class seats lost their ground to business jets, where VIPs can choose not only the time, destination, but the most valuable thing: who's sitting on the first seats.

Don't get me wrong. I ain't saying that experience is not important. But once I got asked:

"Which one would you hire? 22 thousand flying hours or 5 thousand?"

I also blindly answered "The most experienced for sure."

To my surprise the reply was something like: "Well, I'd hire the one that does not hit a seawall during a visual approach or crashes into the ocean from a 10 minute fall".

Rozy1
29th Apr 2022, 07:48
If both pilots believe the aircraft is going in the wrong direction (with only one being right about the direction), both are going to take action because they both believe (with only one being right) that the aircraft is in a bad position, and one golden rule is "if things don't go as expected, take action"

For your first point, spatial disorientation can happen, it has happened before to pilots from all over the world, it will probably happen again.
Maybe standardizing the attitude indicator would avoid a fraction of these disorientations.

Ok dasku, are you saying if you are in the cockpit and see some concerning maneuver start, you’d just start opposing the other pilot if you weren’t the PF, AND SAY NOTHING?

Spatial disorientation is something that should have gone long before you step into a triple. Scan anyone? FFS

BuzzBox
29th Apr 2022, 08:10
I don't see it that way. FO was the PF. CA should never touch the controls without announcing it (but probably veeery used to do things like that, most likely doing that for years, until he almost killed everybody). Also, you're biased thinking that it was the captain counter-reacting the FO input. Somone could clearly state the other way around since these events happened simultaneously. I'd say that we have another somatogravic illusion case here. But let's wait for what BEA has to say.

I totally agree the Capt should not have made control inputs without first taking control of the aircraft.

Biased? Where did you get that from? I could not care less if it was the Capt or FO. That said, have a close look at the traces in the flight parameters section of the report. The control column traces closely follow each other until slightly after the FO's control column began to move further aft at 07:51:16.

The Blu Riband
29th Apr 2022, 09:55
https://en.wikipedia.org/wiki/Air_France_accidents_and_incidents

https://executiveflyers.com/most-dangerous-airlines/

ATC Watcher
29th Apr 2022, 13:56
https://en.wikipedia.org/wiki/Air_France_accidents_and_incidents
https://executiveflyers.com/most-dangerous-airlines/
Both lists cannot be taken as serious references, some airlines as a tenth of the size of others, some fly long haul , some short haul in a first class country, others only fly in developing world countries with basic infrastructure and constant tropical weather, etc. and the largest airline in Europe, Ryanair is missing from this survey. .
On the Wki AF incidents and accidents , a Greenpeace graffiti on an aircraft is noted there as an airline incident, but accidents such as the hard landing ( Caracas) ,or the landing outside of runway ( Cayenne) and a few more serious incidents are missing
If you want a serious list go to the BEA or NTSB not self made lists by non professionals.

zzz
29th Apr 2022, 14:38
The whole thing is a dogs dinner from start to finish.
It starts with the decision to manually fly the approach after a 2-crew night flight when the viz is low and the cloud base is just above Cat 1 decision height. What follows is a localiser deviation, caused either by the PF or the localiser signal itself. The PM at some point starts to make un-announced control column inputs and a go around is flown from around 1000’. Plenty of time to perhaps rehearse the go around actions before pushing TOGA. TOGA is then pushed but there’s no call for a flap change despite having landing flap set. After about 20 secs the PF notices a positive climb and puts the gear up. What’s PM doing at this point? The gear goes up whilst we still have landing flap and we get the config warning. Not ideal during a busy period. The PF over pitches to 24 degrees and the PM instead of clearly taking control pushes the other way and we get a control column breakout/disconnect. Other stuff going on too, second TOGA push for example but that’s the nuts and bolts of it. A total shambles.

What would I have done differently. I’d have started by suggesting to the FO that maybe today wasn’t the day to practice his hand flying skills. If it was going wrong on the approach I’d have suggested putting in the AP and going around. Failing that “I have control” as a last resort.

It would be interesting to know the relative experience levels of the two pilots. Older and more experienced First Officers can make for an interesting dynamic.

l guess we will know in due course!

BuzzBox
29th Apr 2022, 18:22
The whole thing is a dogs dinner from start to finish…

Yes to all that. Note the go-around commenced at about 800 ft above the threshold height (26L threshold elevation 316 ft). Possibly not the best time to be ‘rehearsing’ the go-around procedure!

zzz
29th Apr 2022, 19:08
Agree, if hand flying as per this case.

Scagrams
29th Apr 2022, 20:01
Yes to all that. Note the go-around commenced at about 800 ft above the threshold height (26L threshold elevation 316 ft). Possibly not the best time to be ‘rehearsing’ the go-around procedure!

I do find a 5 sec pre brief of the go around is extremely useful in cases like. 800 ft isn't a lot of margin but I'd feel confident taking few seconds to just remind the other guy what we're about to do up until 500' AGL. It is standard practice in my company nowadays

Klauss
30th Apr 2022, 04:23
Hi, the go-around was a mess, according to the BEA press release.
The question that I have is , how and why the 777 needed a go-around in the first place.
I mean, what about the control inpunts that gave it a left bank, with up to 60 deg. control wheel deflection ?
Any thoughts on those ?

FullWings
30th Apr 2022, 14:32
It almost looks like some kind of incapacitation, and that the PF “lost it” for a bit. Agree about the lack of an announced takeover being contributory; it’s difficult to work out who was doing what for a while but I suspect the PF still had the thrust levers even though the PM was providing much of the pitch/roll input. Aeroplanes can be operated multi-pilot but most of them are designed for only one person at a time on the flying controls.

There may be more revelations that change the look of it but at the moment it doesn’t appear to be their finest hour...

CVividasku
30th Apr 2022, 22:39
Hi, the go-around was a mess, according to the BEA press release.
The question that I have is , how and why the 777 needed a go-around in the first place.
I mean, what about the control inpunts that gave it a left bank, with up to 60 deg. control wheel deflection ?
Any thoughts on those ?
They performed a go around simply because the PF thought the airplane was not anymore in the stabilized approach conditions, and thinked he could not stabilize again within the limit.
Stabilization criteria include bank angle.

wheels up
1st May 2022, 05:38
A number of things don’t make sense here: Firstly the ADS data suggests that the localiser deviation occurred after the initiation of the go around, not as the report suggests that the go around was as a result of the deviation. The report states that the pf was flying manually - you can clearly hear the autopilot disconnect wailer during the incident - as far as I recall (never tried) pushing the AP disconnect when the A/P is already disconnected would not trigger the wailer. Lastly the master warning is clearly audible - the only thing I can think of that would trigger that would be a config gear warning.

silverstrata
1st May 2022, 06:08
.
Do Air France use V-bar flight directors?
(Reason for extreme control inputs.)

I had a similar situation, when the copilot started mixing the (bright pink) flight director with the (black) aircraft index on the attitude indicator. The FD said turn left, and he thought the aircraft was turning left (mixing FD with aircraft index), so he gave the aircraft full right, and nearly turned the aircraft upside down. Again, this was just at 1500 ft on t/o, at night with no ground lights. Luckily the aircraft shouted ‘bank angle’, while I was changing frequency, and I recovered.

Note: In the AF go-around the FD would have indicated 10 degree up pitch, or less if the speed had dropped off. If the f/o was mixing FD and aircraft index, he may well pull back harder - not understanding why the aircraft index (aka the bright pink FD) was not moving with his inputs. So he pulls harder and harder.

P

wheels up
1st May 2022, 06:50
No, standard Boeing FD bars. First push of TOGA commands pitch for 2000 fpm climb, not 10 °.

BuzzBox
1st May 2022, 07:28
First push of TOGA commands pitch for 2000 fpm climb, not 10 °.

Ummm, no. First push of either TO/GA switch commands the go-around pitch attitude (around 15°). The autothrottle activates in THR mode to provide sufficient thrust for a minimum climb rate of 2,000 ft/min.

Uplinker
1st May 2022, 08:12
The adverse human view continues, ‘aircrew’, … ‘error’ - a definition after the fact..

Can I just say that in my posts about crews or pilots, I am not having a go at the individuals, I am simply trying to understand why supposedly highly trained, examined and experienced individuals cannot do something as simple as, for example : watch their IAS and correct it if necessary, or perform a go-around.
(And in the three reasons you give for blaming recent incidents on aircraft design (which also involves humans); remember, if the automatics are not doing what is needed, pilots should reduce the level of automation, perhaps as far as taking fully manual control, if necessary).

I am deeply concerned and worried about the apparent reduction of flying safety that seems to be happening. We are not even talking about serious mechanical failures such as double engine failures or an engine exploding and causing major damage - (all three recent examples of which were expertly flown by the pilots and crews by the way, as I said).
No, we are seeing absolute bread-and-butter - very easy manoeuvres - that are being botched - in some cases with fatal results. Why? No pilot goes to work intending to do a bad job, so what is going on with selection, testing and recurrent training?

And should I be concerned about going on a flight with my family, in case the pilots don't remember how to take-off or land, or go-around? A ridiculous question, surely?
.

172_driver
1st May 2022, 09:47
No, we are seeing absolute bread-and-butter - very easy manoeuvres - that are being botched - in some cases with fatal results. Why? No pilot goes to work intending to do a bad job, so what is going on with selection, testing and recurrent training?

We have really got ourselves to blame really for becoming operators rather than pilots. 6-month scripted recurrent training does not necessarily prepare you for life on the line.
Flying the later approach manually may not have been the wisest decision under the circumstances - but it shouldn't have been a problem. That's the elephant in the room. We're really only a failure from a total **** show.

With the risk how hubris. I was FO to a Captain how tried a to pull off a raw data to a 200 ft ceiling after he had seen me do a couple during the day. It didn't end well, he asked if I could take over (big of him!) which I did. Below the deck I gave it back to him so he could practice his smooth landings.

Uplinker
1st May 2022, 10:23
As normal line pilots, we don't dictate our training, (or our SOPs).

At a (now defunct) UK airline, I asked the training management if I could use the cardboard bomber they had at head office in my own time, after hours, to practise memory drills and scenarios etc., on my own.

No they said, (gee, thanks guys), so I was back to practising stuff using a half-sized cockpit poster in the spare room at home.

FullWings
1st May 2022, 10:49
The report states that the pf was flying manually - you can clearly hear the autopilot disconnect wailer during the incident - as far as I recall (never tried) pushing the AP disconnect when the A/P is already disconnected would not trigger the wailer.
It goes off when you press the button regardless of whether the AP was in or not, certainly on the ones I fly.

BuzzBox
1st May 2022, 11:06
At a (now defunct) UK airline, I asked the training management if I could use the cardboard bomber they had at head office in my own time, after hours, to practise memory drills and scenarios etc., on my own.

No they said, (gee, thanks guys), so I was back to practising stuff using a half-sized cockpit poster in the spare room at home.

That's just stupid. At the airline where I formerly worked, we could use the procedural training devices (fixed-base) any time they weren't needed for conversions, etc, on a first-come, first-served basis.

alf5071h
1st May 2022, 15:32
Uplinker, #170, I appreciate your comments and in principle, agree.

You identify a key aspect, the inability to understand after the fact; the human element, human factors, ourselves. There are many different approaches to this, scientific and practical, significantly that by identifying issues which we can learn are of greater value opposed to attempting to ‘understand’ error.

One issue is the inherent uncertainty in situations and human behaviour, humans abhor uncertainty thus fill in the gaps, some of which involves assumptions. e.g your “… supposedly highly trained, examined and experienced individuals cannot do something as simple as …” might assume standards of training, checking, or that the situation as perceived by the crews was ‘simple’.

To us with hindsight yes, but to a surprised crew (or do we assume that crews should not be surprised), their comprehension of the situation is built on what they ‘see’ at that time (that instant which we cannot revisit).

We should not seek absolute understanding, nor comparison; instead consider the uncertainties in the situation, aspects what we don't or cannot know. Avoid what is / was, and alternatively consider what could be / have been. Question if there are issues from which we might learn.

Other posts have diverse views - a simple GA; but with an apparent control malfunction - ‘simple’ is redefined.

‘Everything in war is very simple. But the simplest thing is difficult.’ Von Clausewitz

Uncertainty requires judgement at the time; hindsight assumes knowledge after the fact, clarity, yes-no decisions, and procedural perfection.

wheels up
1st May 2022, 16:53
Ummm, no. First push of either TO/GA switch commands the go-around pitch attitude (around 15°). The autothrottle activates in THR mode to provide sufficient thrust for a minimum climb rate of 2,000 ft/min.

I wrote that badly - the FD pitch bar will adjust as soon as you start climbing to command speed, the pitch commanded is obviously dependant on the thrust set so yes it does pitch to give 2000 fpm. Don’t think the initial pitch commanded is a fixed value, certainly not 10° - probably an increment below the PLIs but good luck finding that in the FCOM. In this case the PF pushed the TOGAs twice and got THR REF, which gave 23° pitch in this case to maintain the speed. Things happen fast at 23° pitch with THR REF.

8che
1st May 2022, 18:15
Ummm no again...

It commands a MINIMUM of 2000 fpm not 2000.

The initial pitch attitude commanded is what is required to maintain the actual IAS when the TOGA was pressed. (Min command speed up to window +25)

BuzzBox
1st May 2022, 23:32
In this case the PF pushed the TOGAs twice and got THR REF, which gave 23° pitch in this case to maintain the speed. Things happen fast at 23° pitch with THR REF.

The TO/GA switches were pressed once at the start of the go-around and the attitude increased to about 14° and stayed there for three seconds. The attitude started increasing again at about 07:51:17 and the TO/GA switches were pressed a second time at 07:51:20. By that time, the attitude had already increased to about 20°.

Dropp the Pilot
2nd May 2022, 00:11
Pushing the TOGA switch a second time will have caused the thrust to increase from an already generous amount to full whack. On an airplane at max landing weight that would have changed the maneuver from impressive to full-on carnival ride. Clearly they weren't awake before, but they will be now.....

alf5071h
3rd May 2022, 07:57
Re safety concerns (comfort level) #179, the study - ‘Distress call from the flight deck: Cross-Cultural survey of aviation professionals reveals perception that flight safety is decreasing’, identifies the issues. https://www.researchgate.net/publication/268271017
A short extract for those who cannot get full access:-

Safety in numbers
In response to the question “Do you think aviation is safe?” several people responded “yes…”, paused, seemingly conflicted, and then qualified their response with explanations like: “it is statistically safe” or “safer than all the other modes of transportation”. They generally described behavioural, procedural, and operational examples of “safety” in their daily work. This revealed a distinction between safety as the active experience of an activity (e.g. flying) in contrast to the “safety level” described by statistics reflecting the outcomes of that activity (e.g. fatalities or hull losses). A review of the interview data reveals that, with very few exceptions, safety was discussed as the qualitative, tangible experience of the risk involved in the activity, and this risk is compared to some cognitive or affective baseline – what could be considered the “comfort level” of the individual. Although it may seem obvious that practitioners will not discuss safety in terms of trends and statistics, it is relevant to our community of researchers and decision-makers to occasionally remind ourselves of the distinction. Accident statistics based on outcomes are used as the universal measure of safety presented to the public as well as for risk management and in decision-making. The interview data highlights the disconnect between quantitative safety statistics and ‘real-time safety’ as part of the ongoing, dynamic, daily activities of pilots, controllers, and other aviation professionals. Logically it seems that the two are not independent: if the work is not carried out in a conservative, consistent, conscientious manner (i.e. “safely”) then the statistics should reflect that and aviation’s laudatory safety record will not be maintained. Over time. But who can afford to wait for the statistics to prove the veracity of these warnings?

Conclusion
Through this study of the differences in perspectives and beliefs of aviation professionals across national cultures, the trade-off between economic and safety interests was identified as a common concern. According to a diverse sample of pilots and controllers, while aviation statistics may still portray a healthy industry, the operational reality is another matter altogether: the impact of economic scarcity and the ever-increasing focus on profits has reduced safety through changes in management practices, organisational structure, and regulations.

With very low accident rates, should the regulators change their safety perspective?

In this incident, assuming that either a mechanical restriction or crew interaction contributed to the situation (presumably unforeseen), then is risk viewed as a threat - regulatory, statistical risk management, or as a managed risk with a successful outcome; non fatal normal landing ?

‘… when an employee feels at risk he or she also is at risk. Thus, “the risk of accidents are increased not because of a biased perception of risk, but rather because risk is perceived ‘correctly’, i.e. is in accordance with objective [Regulatory statistical ?] risk”
https://safety177496371.wordpress.com/2021/02/16/associations-between-risk-perception-and-safety/

BoeingDriver99
4th May 2022, 07:08
Interesting paper; now more than ten years old. It's most recent and vivid accidents being Colgan Air and the Hudson River ditching. I would hazard a guess and say that the same people interviewed today would have an even more pessimistic view of the industry.

The problem with increased mechanical reliability, more advanced automation and lowering of T&Cs is that the job doesn't need sharp people anymore. However when things go wrong; those same people are quite clearly out of their depth - this incident and the French Bee A350 and now perhaps the Spicejet in 'turbulence". How is the regulator supposed to get ahead of these 'black swan' events that are by their nature unpredictable and infrequent?

It's simple; the cost to do something about it is is higher than having a hull loss every x million passenger miles. If that relationship reverses; expect something will get done.

Goldenrivett
22nd Jan 2024, 08:09
Final BEA report (https://bea.aero/fileadmin/user_upload/F-GSQJ_finalreport_EN.pdf)

Apparently both crew members applied simultaneous control inputs for 53 seconds resulting in the controls being desynchronised for 12 seconds.

ATC Watcher
22nd Jan 2024, 12:10
When the captain called out "I have the controls", about 53 s after the approach had been aborted, the forces recorded on the right-hand control column became zero and the flight path was stabilized.
but also :
​​​​​​​The investigation revealed that crews had little knowledge of the breakout mechanisms. A certain number of pilots were aware of the existence of this system and often only associated it with a jammed control. The description of the system in the FCOM was limited to an explanation about the risk of a control jamming. The manufacturer's and operator's documentation did not explicitly mention the effects of simultaneous actions on the controls, and this point was not covered in training
and under Safety measures taken after the incident :
​​​​​​​that Boeing supply Air France with information about the operation of the roll and pitch flight control desynchronization mechanisms along with the consequences of the desynchronization for the rest of the flight; ➢ that all the Boeing documentation regarding the operation of the roll and pitch flight control desynchronization mechanisms is made available to crews;

CVividasku
22nd Jan 2024, 15:19
In your opinion, what was the classification of this incident according to the ERC matrix ?
In my opinion, it lies between 2 and 21.
https://www.galiot.aero/images/resourcesPage/articles/Event_risk_classification.png
The flight path was never really dangerous. One call from one pilot was enough to resolve the issue.
There are other systems that help prevent escalation into more serious trouble (EGPWS, TCAS,..)

I have the same question, regarding crashes this time. Ask the exact same questions, however take the accident scenario for question 1, and what should have happened for question 2.
Then go into the matrix. For example AF447 should have been a 502, at worst. Concorde crash was a 2500.
However, some deadly crashes should have been classified 50 or 102. There are many examples where lots of barriers synchronised to be all defective together, whereas they shouldn't have been.

Goth
22nd Jan 2024, 16:59
One interesting thing in the analysis is that the incidence of dual control input in the AF fleet was broadly similar between the A & B. There was much talk around AF447 that it wouldn't have happened with coupled controls, but this incident suggests that it might not be as clear cut as that - that once communication and situational awareness break down, the coupling of the controls may not rescue the situation.

FullWings
22nd Jan 2024, 20:09
From the report:

The following factors may have contributed to the simultaneous inputs on the controls:
• the PM’s reflex action on the controls during the banked go-around, probably linked to
the deflection of the wheel and the unusual pitch attitude;
• failure to formalise the transfer of control;
• the absence of any warning about the effects of simultaneous actions on the controls in
the manufacturer's and operator's documentation for this type of aeroplane;
• the lack of information on the possibility of desynchronization of the controls in the event
of opposing inputs in the documentation available to pilots;
• a lack of knowledge about the systems resulting from this lack of information;
• the conviction that simultaneous inputs on the controls would be quickly perceived by
crews on this type of aeroplane.

The first two points pretty much sum it up IMO.

I'd argue that the simultaneous inputs were perceived almost instantly by both pilots, but due to the general level of arousal attributed to anomalous behaviour of the system rather than input from the other side. I would also point out that it’s fairly obvious when someone has their hands on the controls as they’re sitting next to you - I feel straight away when people use the yoke switches while I’m flying and they get asked to use the ones on the coaming or centre console.

Pretty thorough report, glad to see the 2-crew night Atlantic 24hr trip getting a bit of a spotlight. Try doing six of those a month for six months. Overall though, no surprises - decision making can be collaborative but manual flying is a solo operation pretty much all of the time.

Luc Lion
23rd Jan 2024, 10:09
I am surprised that the deviation from the stabilised approach which is at the inception of this incident is not analysed in this report.
The report states: "with a 6° left bank, and the wheel 17° to the left, the PF called out 'go around'", 6 seconds after stating that the bank angle was "strange".

I guess it means that the PF suffered a somatogravic illusion possibly coupled to some fatigue.
And I understand that, since this deviation has been followed by the correct response, going around, it is not considered as serious as the double input on the commands.

However, in my opinion, it is worth analysing if it was indeed a somatogravic illusion or if it was something else, and checking what might have triggered the illusion at that time, 2.1 nm from the threshold.
Because there has been and there will be other losses of spatial awareness in short final followed by an incorrect response and more tragic consequences.

steamchicken
23rd Jan 2024, 19:49
I am surprised that the deviation from the stabilised approach which is at the inception of this incident is not analysed in this report.
The report states: "with a 6° left bank, and the wheel 17° to the left, the PF called out 'go around'", 6 seconds after stating that the bank angle was "strange".

I guess it means that the PF suffered a somatogravic illusion possibly coupled to some fatigue.
And I understand that, since this deviation has been followed by the correct response, going around, it is not considered as serious as the double input on the commands.

However, in my opinion, it is worth analysing if it was indeed a somatogravic illusion or if it was something else, and checking what might have triggered the illusion at that time, 2.1 nm from the threshold.
Because there has been and there will be other losses of spatial awareness in short final followed by an incorrect response and more tragic consequences.

It's weird isn't it? Literally no discussion of how the approach originally went out of kilter.

Fortissimo
23rd Jan 2024, 22:06
In your opinion, what was the classification of this incident according to the ERC matrix ?
In my opinion, it lies between 2 and 21.
https://www.galiot.aero/images/resourcesPage/articles/Event_risk_classification.png
The flight path was never really dangerous. One call from one pilot was enough to resolve the issue.
There are other systems that help prevent escalation into more serious trouble (EGPWS, TCAS,..)

I have the same question, regarding crashes this time. Ask the exact same questions, however take the accident scenario for question 1, and what should have happened for question 2.
Then go into the matrix. For example AF447 should have been a 502, at worst. Concorde crash was a 2500.
However, some deadly crashes should have been classified 50 or 102. There are many examples where lots of barriers synchronised to be all defective together, whereas they shouldn't have been.

I don't think we share the same understanding of how the ERC works, but I stand to be corrected. It doesn't work for accidents that have happened. It starts with Q1 (funnily enough) which asks what would have been the likely outcome if it escalated into an accident. The most likely outcome of disorientation IMC and at low level is LOC-I, which is going to be catastrophic. Only then do you start to look at the effectiveness of the remaining barriers. For this event, the barriers operated but it was limited effectiveness in my view as the control wrestling went on for a full 53 seconds.

If the BEA didn't think it could have escalated into an accident scenario, I suspect there would not have been a full-blown Annex 13 investigation.

RickNRoll
1st Mar 2024, 04:16
https://youtu.be/gxvOHBKj-7o?si=0yi3nuDnzJJ8mWSX

Now we know the reason why it started. PF thought 5G had disrupted his control of the plane. It all went downhill from there.

​​​​​​Boeing ​connected control columns didn't help confusion over who was doing what.

BraceBrace
1st Mar 2024, 07:55
​​​​​​Boeing ​connected control columns didn't help confusion over who was doing what.

All discussions on connected controls "breakout" feature can be boiled down to training IMHO. I cannot believe pilots were not aware of the existance of this feature. However this feature is "presented" in training only as a "solution ico jammed controls". I personally admit I never thought it would be possible that "fighting pilots" would create a similar effect and breakout could be achieved in such a scenario as these forces are fairly high.

A simple demo of both pilots giving opposite inputs in training would create the necessary awareness and avoid future problems.

212man
1st Mar 2024, 16:25
I personally admit I never thought it would be possible that "fighting pilots" would create a similar effect and breakout could be achieved in such a scenario as these forces are fairly high.

​​​​​​​Egypt Air B767?

BraceBrace
2nd Mar 2024, 11:34
Egypt Air B767?

Maybe the wording ”fighting pilots” was a bit too strong. Wasn’t referring to 2 pilots really fighting for death vs living, but 2 normal yet confused pilots simply not aware of eachothers actions. As the recorded deviation in bank/pitch of 767 vs 777 is quite different, you would expect the ’applied forces by the pilots’ to achieve a correction to be quite different as well (hence a lot lower on the 777 flight)

hans brinker
2nd Mar 2024, 18:28
All discussions on connected controls "breakout" feature can be boiled down to training IMHO. I cannot believe pilots were not aware of the existance of this feature. However this feature is "presented" in training only as a "solution ico jammed controls". I personally admit I never thought it would be possible that "fighting pilots" would create a similar effect and breakout could be achieved in such a scenario as these forces are fairly high.

A simple demo of both pilots giving opposite inputs in training would create the necessary awareness and avoid future problems.

Reminds me of the training exercise we did on the DHC8. Came with PULL-TO-DISCONNECT for pretty much all controls in case of flight control jams. This was something of a CRM exercise. Instructor would jam the ailerons, disable the spoilers and the rudder (I think total hydraulic failure). Only thing working was the elevators. If you disconnected the pitch control, and had one pilot pitch and power for altitude, and the other pitch for angle of bank you could fully control the aircraft. Bonus points for differential power in the turns for turn coordination. Don't think it was ever needed in real life, but great to see how important working as a crew is vs not knowing what the other guy is doing.