Air France rejected T/O in Lagos

[DJ77]

As I understand post #56, AF SOPs regarding A/T arming were changed after a 747 incident then were later reverted to the original Boeing procedure i.e. A/T armed at preflight.

I know the first change applied to 747s, 767s and 777s but does anybody know if the reversal also applied to the 777s

[The Snake]

"What is the philisophy behind being able to engage an AP during takeoff in the B777 design? Why isn't this feature inhibited until the minimum engage height?"

Interesting point. During my ATPL theory (2001...long time ago) they told me that modern integrated A/P can't be engaged on the ground. Surprised I was when switching from the BAe146 to the AVRO that it is still possible to engage everything on the ground.

Maybe as the A/P remains engaged during an Autoland until roll-out. The manufacture doesn't want to program altitude engagement limits in their autopilot?

[moonbase]

Arming A/P on T/O rather than ATR

I heard the other day that there have been 7 incidents on the B777 of the autopilots being armed on T/O rather than the autothrottles - does anyone know where these figures came from or what the other incidents were?

[HotelT]

[M2Dude] .. every aircraft that I've ever been involved with has had NO AOG A/P inhibit. It's never been relevent before.

On the MD11 one cannot engage the AP while on ground during takeoff, only the AT. If I remember correctly (it has been a few years since I last flew the MD11), the AP engage button ('Auto Flight' button) is used to engage the AT during takeoff ...

With -reportedly- 7 other incidents on the B777 (how many were not reported?) of pilots inadvertently engaging the AP i.s.o. the AT during takeoff, I would consider it wise if Boeing were to re-evaluate the MCP design (especially if other A/C-types have not shown similar mishaps; why did B744/B737NGs not have similar problems with their MCPs/APs ?). Boeing will probably get away with this incident; any future crash, Boeing will probably be (at least partially) liable.

Nevertheless, I fully agree that non-standard MCP (or Flap, for that matter) selections during takeoff should not be performed nor excused.

My two cents...

[safetypee]

The Snake, IIRC the Avro RJ autothrottle could be armed for take off and engaged by selecting TOGA. The autopilot could not be selected ON when on the ground (squat switches). During an autoland, the autopilot would remain engaged until 80kts where the crew should disengage it, but the system would automatically disengage below 60 kts.
The selector switches were dissimilar and provided an annunciation both at the point of selection (the switch) and in the mode display on the EFIS.

[Longhitter]

The Avro RJ autopilot can be engaged on the ground. It has to be disconnected by pilot action after an autoland as it will not disconnect itself.

[TyroPicard]

M2dude

Errrr... every aircraft that I've ever been involved with has had NO AOG A/P inhibit. It's never been relevent before; no pilot I've ever known has been so daft as to even want and try and do it.

You were never involved with the DC-10-30, then. AP engagement in Manual was permitted for takeoff - saw it done by one daft training captain.

[M2dude]

Wow!! that sure makes you think; I bet there were at least 2 other surprised guys on the F/D.
I've been going through the 777 APFDC A/P engage logic diagrams, and found that in spite of what was previously thought (certainly by myself) there IS a sort of A/P engage inhibit on T/O for the 777. Although you can engage the A/P on the ground, you can NOT if the G/S is above 80KTS with less than 50'RA. However with the A/P engaged there is still nothing to stop the pilot commencing T/O; a la Air France at LOS. The mind boggles!

[S.F.L.Y]

a la Air France at LOS. The mind boggles!

This is certainly a more reasonable comment than the undocumented allegations you are making in the concorde thread with your Captnintendo dude.

[Max Angle]

Some aircraft do have an inhibit for AP engagement on the ground, namely the FBW Airbus family which prevents engagement until 5 seconds after take-off.

[M2dude]

Ah, ok..wasn't sure about the Airbuses Max Angle; thanks. I've checked the 747-400 engage logic diagrams abd there does not seem to be any such 777 equivilent. (Older design I guess).

[HotelT]

A/P logic is one thing, then there is the ergonomics of the B777 panel:

The B777 has two A/P buttons, on the (far) left- and the (far) right-hand side of the MCP (APFDC) .. and the A/P disengage bar smack in the middle. On the left-hand side, it is easy to make a mistake with the A/T button; on the right-hand side it is easy to mistake with the APP button. According to simulator instructors on the B777 mistakes are frequently made (especially with relatively new guys and galls), since all buttons are the same size and feel, only slightly different in text (even worse in night-like conditions, such as the departure ex-LOS, especially for the age 40+ drivers amongst us). If you compare that to the B744 (3 buttons on the right-hand side) and B737NG (4 buttons above A/P disengage bar), the main difference is obvious: the location of the A/P buttons.

All change is not progress...

[Phantom Driver]

Lot of hot air circulating here. Seems like many have forgotten the basic requirement (already pointed out by earlier posters in this thread), viz;....READ/ANNOUNCE THE FMA!!

I suspect quite a few operators aren't bothering with, or are ignoring, this aspect of glass cockpit ops. Please stop trying to lay all the blame on cockpit ergonomics and instead focus on our own shortcomings of not adhering to basic SOP's.

On two occasions, (early days on the 744), I mistakenly activated TOGA switches, once on the ground while taxiing for take-off, due to the bad habit-(very quickly discontinued )-of using the palm of the hands to bring all 4 thrust levers back to idle, which lead to pressure on the TOGA switches. The second time was on finals, manual flying, and brain seizure going for TOGA switch rather than A/T disconnect. All due to inexperience on the machine at the time.

However, the point I wish to make is--on both occasions there was absolutely no drama whatsoever; One is instantly aware of the uncalled-for spoolup (in the ground event,a surprisingly smooth affair; not sure if this a designed intent by Boeing engineers for the 74, as I haven't experienced it/made a similar c**k up on another type). PM called the FMA on both occasions to confirm what was happening; a quick prod of the correct button (A/T disconnect) instantly solved the problem. reset the FD's and business resumed as normal.

One wonders why AF, with allegedly similar occurrences, saw fit to make drastic changes to their procedures. Asking for trouble?

[DJ77]

HotelT, your are right, it's easy to confuse the left AP button with the A/T button.

However, the captain had no good reason to fumble with the MCP buttons since hitting the A/T button would have achieved nothing. It is inhibited below 400 ft RA.

Intentionnally or not (the report says the later), he hit the AP button while moving the A/T ARM switches after he realized he had omited them in the OFF position at preflight or before takeoff, depending on the current SOP.

To engage the A/Ts on the ground you have to arm them first, then push the TO/GA switches located forward of the throttle levers. Btw, these TO/GA switches are much less likely to be inadvertently activated than the palm swiches of the 747s so I believe that changing the AF SOPs was widely unjustified for the 777.

[HotelT]

I am not trying to excuse the captain for making non-std selections during takeoff, nor the F/O for not properly monitoring the FMA (although it would have probably taken him a while to compute; not only the totally unexpected FMA readings itself .. but especially the "CMD" -or 777 similar- annunciation). See also my earlier statement "non-standard MCP (or Flap, for that matter) selections during takeoff should not be performed nor excused".

The point I am trying to make is that I would like to know what can be done to prevent further (and worse) mishaps. Why did the captain make these selections in this flight phase? Why was it technically possible to engage an autopilot in a situation in which autopilot use is not intended nor certified? Why the mix-up in buttons? Etc., etc..

It is always easy to blame the pilot (and let me stress once more: I do not approve of his actions), but our training, procedures and technology are intended to provide extra layers of safety in order to prevent such mishaps. Blaming this captain might seem the appropriate (easiest?) thing to do (and maybe even convince ourselves that we are superior in operating aircraft and that these things will never happen to us), but experience has shown this course of action usually will not prevent future mishaps...

As for the hot air.. unfortunately the country I live in isn't as warm as SIN

[stanley]

There was an old DC10 saying which still holds true LIVE or DIE by the FMA

[Phantom Driver]

HT

According to simulator instructors on the B777 mistakes are frequently made (especially with relatively new guys and galls), since all buttons are the same size and feel, only slightly different in text (even worse in night-like conditions, such as the departure ex-LOS, especially for the age 40+ drivers amongst us). If you compare that to the B744 (3 buttons on the right-hand side) and B737NG (4 buttons above A/P disengage bar), the main difference is obvious: the location of the A/P buttons.

Understood, particularly relevant at the moment, as I am in the process of transitioning from the "Queen of the Skies" onto it's (slightly) smaller sister. Points taken; I must admit to searching for the correct buttons in early sessions, but surely this is to do with inexperience on the machine rather than ergonomics? I don't know if this was the case with our AF colleagues, but I do think the engineers have done a great job on the 777.

My concern, as pointed out by others, is that- there is no reason to deviate from basic SOP's and start fiddling with the MCP during the take-off roll, be you PF or PM. Jeez, my instructor just told me off for adjusting the cockpit panel lights while taxiing! Do it beforehand, he said; (fair enough).

especially for the age 40+ drivers amongst us

Indeed!

[Me Myself]

What a load of tosh really !! 40+ and you already consider yourself an ergonomic write off ? Pathetic !
The auto pilot and the ATHR, although really close, can in no way be mistaken for one another, even if you are transitioning from..........er........the queen of the sky ??? Good grief ! How old are you ??
One is your simple square knob when the other(s) are 2 big, popping out, enough levers. Unless you have fatal brain injuries, there is no way you can make that mistake...................unless you commit the unforgivable sinn of being hasty.
That's where you get bitten.
Trust me, that poor fellow has a lot of time on his hands to think about it now..........sitting at home and not by his own choice if you get my drift.

[Phantom Driver]

40+ and you already consider yourself an ergonomic write off ? Pathetic !

Suggest you re-read what I had to say regarding "ergonomics" with just a little bit more attention. I think the present discussion is about A/T and A/P select BUTTONS (identical in appearance and closely spaced), not A/T arm SWITCHES on the 777 (Air France SOP's notwithstanding).

No excuse for what the guy supposedly did,(ALLEGEDLY hitting A/P instead of A/T button); maybe only mitigating circumstances here, but no question that even those would be hard to defend.

As I stated-

there is no reason to deviate from basic SOP's and start fiddling with the MCP during the take-off roll,

Which doesn't mean we haven't all been guilty of doing that at one time or other........?

[fdr]

Ergonomics....

HT, Fantom:

Interesting discussion, and the honesty is refreshing.


"How many things, both just and unjust, are sanctioned by custom!"
Terence (c. 185 or c. 195– B.C.), Heautontimoroumenos. Act iv. Sc. 7, 11. (839.)

After 7 previous events, AF and potentially ANZ's, it is fair to assume that the manufacturer will be looking at changes with some enthusiasm.

The matter of SOP's becomes moot (overstated, actually becomes probably far more important...) on far too many occasions as a direct consequence of the crews being humans; it is a natural human response to attempt to correct an error, particularly when one may realise it is likely caused by the individual. The sudden flicking of switches, contrary to SOP's, 2 crew philosophy and common sense is nevertheless all too often the outcome. This is an observation from a fairly wide spectra of operators, class leaders and laggers as well. The same behavior is exhibited by line crew, instructors in simulators, TRI's TRE's etc.... within my observational history. This includes multiple airlines within alliance(s).

(Assuming my observation has any relation to the normal industry behavior, then) the defence mechanism is to ensure that where the operation goes pear shaped, that at the very least the monitoring pilot conducts a review of primary operating criteria... aviate-navigate-communicate, including the basic stuff such as FMA status vs desired. It is natural that the operating pilot/"system switch flicker", will have an instantaneously increased workload due to the non standard processes he/she has gone through that result in taking the non standard action, which places them at a disadvantage in performing reliably a self analysis of their actions and it's consequences. More formally, the individual is confronted with a sudden awareness of a Situational Awareness Type I, II, or III slip, and that their mental model of the world is suddenly (and occasionally dramatically) proved to be false.

Perception (Level 1 SA): The first step in achieving SA is to perceive the status, attributes, and dynamics of relevant elements in the environment. Thus, Level 1 SA, the most basic level of SA, involves the processes of monitoring, cue detection, and simple recognition, which lead to an awareness of multiple situational elements (objects, events, people, systems, environmental factors) and their current states (locations, conditions, modes, actions).

Comprehension (Level 2 SA): The next step in SA formation involves a synthesis of disjointed Level 1 SA elements through the processes of pattern recognition, interpretation, and evaluation. Level 2 SA requires integrating this information to understand how it will impact upon the individual’s goals and objectives. This includes developing a comprehensive picture of the world, or of that portion of the world of concern to the individual.

Projection (Level 3 SA): The third and highest level of SA involves the ability to project the future actions of the elements in the environment. Level 3 SA is achieved through knowledge of the status and dynamics of the elements and comprehension of the situation (Levels 1 and 2 SA), and then extrapolating this information forward in time to determine how it will affect future states of the operational environment.

"Vigilance and Workload in Automated Systems
Joel S. Warm

William N. Dember

University of Cincinnati

Peter A. Hancock

University of Minnesota

INTRODUCTION
Active vs. Supervisory Control
Vigilance or sustained attention refers to the ability of observers to maintain their focus of attention and to remain alert to stimuli for prolonged periods of time ( Davies & Parasuraman, 1982; Parasuraman, Warm, & Dember, 1987; Warm, 1984, 1993). This aspect of human performance is of considerable interest to human factors/ergonomics specialists because of its vital role in automated human-machine systems ( Howell, 1993; Warm, 1984). As Sheridan ( 1970, 1987) noted, the development and utilization of automatic control and computing devices for the acquisition, storage, and processing of information has altered the role of the human operator in many work settings from that of active controller to that of executive or supervisor. Thus, in settings such as military surveillance, industrial quality control, robotic manufacturing, seaboard navigation, nuclear power plant operations, long-distance driving, and prodromal symptom monitoring in intensive-care units, observers must attend to a wide variety of displays for untoward events and take effective action when they are noted. As Parasuraman ( 1986) said, the responsibility for target detection in today's highly automated systems may be allotted to instruments and controls, but human operators are still needed when systems malfunction or unusual events occur. In some cases, such as aircraft and nuclear power plant accidents, vigilance failures can be disastrous."

"Fault Management in Aviation Systems
William H. Rogers

Paul C. Schutte

Kara A. Latorella

NASA Langley Research Center

INTRODUCTION
Fault management gone awry rarely has disastrous consequences in commercial aviation. The Boeing Commercial Airplane Group ( 1994) reported that 120 hull loss accidents with known causes have occurred over the last 10 years. Of those 120, 13 have involved airframe, aircraft systems, or power plants. Most of these involved older-generation aircraft. Improved fault management may have avoided some of these accidents, but probably not all. Systems on today's aircraft have tremendous reliability and built-in redundancy. Fault management is generally performed very well. But when a fault is not handled properly, people can die, equipment can be lost, and careers can be needlessly ruined. Human error, in this case mismanagement of faults, as pointed out by Rasmussen ( 1986), should be taken as the starting point rather than the conclusion of investigation. Human error can be caused by fundamental human attentional and cognitive limitations and biases, as well as environmental and contextual factors. Improved fault management must be grounded in an understanding of human performance and the operational environment in which pilots and automation together must perform fault management."


In the AF case, the basic event could be characterised as an omission of a procedural step, SA-I failure, which results in an operational abnormal condition, ATR fails to function. The operator identifies the failure, and takes either SOP+non SOP action, or just non SOP action, which results in the AP being accidentally engaged, a further SA-I error. The non standard activity on the MCP increases workload and reduces monitoring resources, and results in failure to pick the AP/SA-I error, and at rotate results in the behavior of the flight control system being erroneously identified as a flight control problem (arguable, there is a restriction of the flight controls, but the causation is incorrect AP mode vs a flight control system malfunction). Overall, the initial SA-I failure results in action that causes a further SA-I failure resulting in an SA-II failure and consequent SA-III failure.

[back in the late 80's a research project I was involved in tried deliberately messing with this on some subjects, and after the first victims trials, was promptly terminated; the shock of the individual suddenly realising their mental model is erroneous is notable. reminds me of the saying that the fall doesn't kill you, it is the sudden realisation you were so stupid....].

While an SOP and good training may act to dampen the enthusiasm of the pilot to flick switches, the greatest strength may well be in using the same SOP's and training for the monitoring pilot to have heightened awareness of their importance in breaking the event chain by responding to non standard procedures, and abnormal operational processes by checking the basic stuff.

Error Mgt.... as we remain human and therefore prone to mussin' up....

[and before that is taken as an admission of the design supremacy of removing the human from the loop, my Windows Vista locks up far too often to have faith in mankind's short term ability to design an infallible system...]

"Error has no end." Robert Browning (1812–1889) Paracelsus. Part iii.

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