Afriqiyah Airbus 330 Crash
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What would you accept as evidence?
Just SLF here but becoming somewhat alarmed by this thread as I don't fly well at the best of times but I have a question for ELAC ...
That statement
"the evidence supporting that a lack of hand flying proficiency is a significant problem does not appear to exist;" begs the question as to what you would accept as examples of such evidence?
Obviously I note your use of the word 'significant' and I'm not offering this as evidence but I think I've read somewhere of a Thomson flight into Bournemouth in 2008 can't find the link right now which was forced to GA after a decay of speed on approach (when the AT dropped out unnoticed??) where hand flying skills certainly seem to have saved the day in a way in which they didn't at Buffalo ... but I do acknowledge I'm not a pilot and writing from a considerable degree of ignorance.
That statement
"the evidence supporting that a lack of hand flying proficiency is a significant problem does not appear to exist;" begs the question as to what you would accept as examples of such evidence?
Obviously I note your use of the word 'significant' and I'm not offering this as evidence but I think I've read somewhere of a Thomson flight into Bournemouth in 2008 can't find the link right now which was forced to GA after a decay of speed on approach (when the AT dropped out unnoticed??) where hand flying skills certainly seem to have saved the day in a way in which they didn't at Buffalo ... but I do acknowledge I'm not a pilot and writing from a considerable degree of ignorance.
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After sitting on the sidelines and watching this post grow and grow, I just wanted to add a couple of comments.
I have seen the data and I can assure you things went wrong prior to the missed approach. There are several issues that, hopefully, will appear in the accident report.
There was no spatial disorientation, at least, there is no evidence to suggest that in the CVR and I doubt if that will be mentioned in the final report at all.
What hopefully emerge is there are systemic problems that exist that led to the accident. I really don't want to go into any further detail right now. However, I think jaws will drop when the final report, data plot and CVR are released.
I have seen the data and I can assure you things went wrong prior to the missed approach. There are several issues that, hopefully, will appear in the accident report.
There was no spatial disorientation, at least, there is no evidence to suggest that in the CVR and I doubt if that will be mentioned in the final report at all.
What hopefully emerge is there are systemic problems that exist that led to the accident. I really don't want to go into any further detail right now. However, I think jaws will drop when the final report, data plot and CVR are released.
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BOAC,
Something we can say is that usually 1000 feet AGL is about 3 miles final and one minute from touchdown is also somewhere between 2 and 3 miles final.
But these are criteria for a stabilized approach. Seeing how it all ended up, I have some doubt if that approach was a stabilized one ... What was the speed, what was the altitude, what was the ROD, 10 miles final, 3 miles final ... ?
Just publish the DFDR data, there is enough interest here (not to say knowledge) to think about all that.
Something we can say is that usually 1000 feet AGL is about 3 miles final and one minute from touchdown is also somewhere between 2 and 3 miles final.
But these are criteria for a stabilized approach. Seeing how it all ended up, I have some doubt if that approach was a stabilized one ... What was the speed, what was the altitude, what was the ROD, 10 miles final, 3 miles final ... ?
Just publish the DFDR data, there is enough interest here (not to say knowledge) to think about all that.
Originally Posted by ELAC
The result may be a ropey approach outside of stabilization criteria, a botched one with a g/a, an overtasked PM who misses something that he should have been doing because he's preoccupied with either FCU/MCP inputs being directed by the PF, or perhaps needing to call out exceedances and corrections to the PF, and etc. Those can be considered as extra risks introduced to the system as a result of the policy.
- You are correct in your assessment, but it could be about time to accept those temporary "extra risks" if you want to improve the overall situation in a near future.
- If a crew is not comfortable with its manual flying during an approach, just press again the 2 or 3 buttons to give back the controls to the airplane.
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ELAC:
What's new under the Sun is the total ineptness with the Turkish Air and Colgan crews; the obvious lack of basic attitude instrument flying skills.
It's pertinent because you come across as being a state-of-the-art pilot unlike those of us who have been "expelled from the club." Sounds like your operations today are much like what we did in the Dark Ages. 
Yes, to a degree perhaps I am fixating on your "far too many" statement. But, "If only a few ... is far too many", well there have always been "a few", so what exactly is new under the sun?
About RNP AR qualification, the answer is no, the regulatory authority that has jurisdiction over my carrier has yet to implement that standard, and as a consequence it is not in use with my company. But then, what does that have to do with the price of tea in China?
Phil Squares:
If the problems referred to here are 'systematic' then it is of the utmost urgency to have the report released as soon as possible, because the implication is that these same 'issues' most likely still exist right now. So the ticking time bomb is still counting down? 
- GY
What hopefully emerge is there are systemic problems that exist that led to the accident. I really don't want to go into any further detail right now. However, I think jaws will drop when the final report, data plot and CVR are released.
- GY
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First it was Sitting Bull; now we have Phil Squares, both smugly telling us that they know what happened but are not prepared to divulge their secrets.
If, for some good reason, they cannot say what happened, why are they revealing that they have such knowledge?
I couldn't possibly comment!
If, for some good reason, they cannot say what happened, why are they revealing that they have such knowledge?
I couldn't possibly comment!
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First it was Sitting Bull; now we have Phil Squares, both smugly telling us that they know what happened but are not prepared to divulge their secrets.
If, for some good reason, they cannot say what happened, why are they revealing that they have such knowledge?
I couldn't possibly comment!
First of all, the only reason I made any comments on this post was because of the direction it had taken. The thoughts on this subject are way off! I merely wanted to get this topic back where it needs to be.
I am not at liberty to say what the DFDR/CVR has revealed. However, I will say, there are fundamental issues that need to be addressed. The problems that resulted in the loss of the aircraft were the result of many issues, some within the airline, some external to the airline. But, the bottom line is going to be the majority of the fault will go to the crew. In reality, it's more a breakdown of the concept of a "crew".
If the problems referred to here are 'systematic' then it is of the utmost urgency to have the report released as soon as possible, because the implication is that these same 'issues' most likely still exist right now. So the ticking time bomb is still counting down?
I will say that measures are already in place and others are being implemented to ensure this does not happen again at 8U. There will be some very painful days ahead but in the end, the carrier should be a better place.
If, for some good reason, they cannot say what happened, why are they revealing that they have such knowledge?
I couldn't possibly comment!
First of all, the only reason I made any comments on this post was because of the direction it had taken. The thoughts on this subject are way off! I merely wanted to get this topic back where it needs to be.
I am not at liberty to say what the DFDR/CVR has revealed. However, I will say, there are fundamental issues that need to be addressed. The problems that resulted in the loss of the aircraft were the result of many issues, some within the airline, some external to the airline. But, the bottom line is going to be the majority of the fault will go to the crew. In reality, it's more a breakdown of the concept of a "crew".
If the problems referred to here are 'systematic' then it is of the utmost urgency to have the report released as soon as possible, because the implication is that these same 'issues' most likely still exist right now. So the ticking time bomb is still counting down?
I will say that measures are already in place and others are being implemented to ensure this does not happen again at 8U. There will be some very painful days ahead but in the end, the carrier should be a better place.
PBL, ELAC;
FOQA/FDA/FDM flight data analysis programs, where conceived and implemented as serious trending and risk tools where the concepts of "precursors to accidents" is understood by operations/training people, and providing there is appropriate, active, daily engagement with the tools between the safety and operations/training people which means FOQA results are routinely, regularly discussed between these groups and taken seriously as indications of the operation and not either disbelieved or denied and hidden, are capable of extending understanding of this aspect of the operation and can in fact pin-point such operational safety problems very accurately. I have seen this work in flight data analysis.
If SOP or skill-related, it would of course be the responsibility of the operations (standards and training) people to determine how best to resolve issues and certainly precursors highlighted by an active FOQA program would assist any such response. Where insituted, trusted and supported by formal agreement between management and the pilots' representative association, providing such circumstances warrant, the (non-management) pilot association gatekeeper can, by crew contact, almost always with the captain first, enquire as to what happened which provides context for the event. Such contact provides informal means by which change can occur through de-identified feedback to operations and training.
Sometimes, in more serious excursions, training is indicated, even up to a more robust intervention, (off roster pending successful training) depending upon circumstances.
I know that this process works successfully.
PBL states:
Precisely. Using any data, even FOQA data, to "plot" risk and "state" that precursors exist is indeed very difficult even if such analysis software has embedded risk analysis tools. While an event or events may be seen in the data, the decision to response, and how to respond, is complex; it can range from a change in SOP to individual training before a return to the roster. FOQA can provide the information upon which such decisions may be made but of course cannot point to the decision itself.
ELAC has highlighted the question of hand-flight very well. For those who always hand-flew, automation is a tool to the point where it can even get in the way of the best operation. For the marginally-skilled who's skill levels have not been sufficiently identified through normal checking processes or formal, (and informal) safety reporting processes, or even through poor or non-existent FOQA monitoring/engagement, automation can mask such a problem until, as ELAC has observed, a serious incident or accident highlights the original problem.
The unfortunate thing is, where implemented at all (beyond a box-tick) and beyond the phenomenon of institutional denial, carriers may view such programs and their necessary infrastructure either as too expensive to support and/or defend at corporate board meetings or too complicated to understand.
Indeed, in my experience, for these exact reasons it has been very difficult to convey such safety information to executives who speak only "market" or "quarterly results" but who control the life-blood of such safety programs.
PJ2
Originally Posted by ELAC
. . . but a significant increase in risk for the small group who fall into the below average ability and below average judgement category. This is the group least likely to be aware when they choose the wrong place to practice a skill which is not up to snuff and needs improvement. You might say, well they shouldn't be there at all, and this would show them up, but the truth is there will always be a small percentage in this category, and the means for finding and improving them should not be the readout of a FOQA event or worse.
If SOP or skill-related, it would of course be the responsibility of the operations (standards and training) people to determine how best to resolve issues and certainly precursors highlighted by an active FOQA program would assist any such response. Where insituted, trusted and supported by formal agreement between management and the pilots' representative association, providing such circumstances warrant, the (non-management) pilot association gatekeeper can, by crew contact, almost always with the captain first, enquire as to what happened which provides context for the event. Such contact provides informal means by which change can occur through de-identified feedback to operations and training.
Sometimes, in more serious excursions, training is indicated, even up to a more robust intervention, (off roster pending successful training) depending upon circumstances.
I know that this process works successfully.
PBL states:
Originally Posted by PBL
It is a hard question to answer. A risk analysis is appropriate, but this analysis suffers from considerable uncertainty in many of its parameters.
ELAC has highlighted the question of hand-flight very well. For those who always hand-flew, automation is a tool to the point where it can even get in the way of the best operation. For the marginally-skilled who's skill levels have not been sufficiently identified through normal checking processes or formal, (and informal) safety reporting processes, or even through poor or non-existent FOQA monitoring/engagement, automation can mask such a problem until, as ELAC has observed, a serious incident or accident highlights the original problem.
The unfortunate thing is, where implemented at all (beyond a box-tick) and beyond the phenomenon of institutional denial, carriers may view such programs and their necessary infrastructure either as too expensive to support and/or defend at corporate board meetings or too complicated to understand.
Indeed, in my experience, for these exact reasons it has been very difficult to convey such safety information to executives who speak only "market" or "quarterly results" but who control the life-blood of such safety programs.
PJ2
Last edited by PJ2; 23rd Jun 2010 at 18:55.
Phil Squares
Your objective is great
The way to do this in a public internet, having privelged information, is to Lead by offering food for thought to the discussion. Else your methods become the subject rather than the message.
First of all, the only reason I made any comments on this post was because of the direction it had taken. The thoughts on this subject are way off! I merely wanted to get this topic back where it needs to be.
The way to do this in a public internet, having privelged information, is to Lead by offering food for thought to the discussion. Else your methods become the subject rather than the message.
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Teevee,
The best place to look would be in a broad sampling of FOQA data spread across carriers, aircraft types, nations and cultures. Look for exceedances that relate either to hand flying or where poor monitoring allowed the autoflight to create an exceedance. Then look at the relative rates of manual approaches. Do that and run a rolling 5 year trend over a period of say 10 years and you'd probably get a pretty good idea of whether you have an increasing problem. pj2 is the man who could tell you best how to do it.
If you didn't have the FOQA data the next step up would be to look at cumulative incident reports. Last, and least effective is to just look at accidents. It's the precursors that never show up on the 9 o'clock news that are the best indicators of whether there's a trend that needs correcting.
ELAC
What would you accept as evidence?
If you didn't have the FOQA data the next step up would be to look at cumulative incident reports. Last, and least effective is to just look at accidents. It's the precursors that never show up on the 9 o'clock news that are the best indicators of whether there's a trend that needs correcting.
ELAC
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Phil,
Thanks for that.
Spatial disorientation has never been more than just a possible explanation for the facts so far reported. More facts would be welcome to help all of us understand the accident, particularly as you suggest systemic problems may underpin it. Let's hope more information is available soon.
ELAc
After sitting on the sidelines and watching this post grow and grow, I just wanted to add a couple of comments.
I have seen the data and I can assure you things went wrong prior to the missed approach. There are several issues that, hopefully, will appear in the accident report.
There was no spatial disorientation, at least, there is no evidence to suggest that in the CVR and I doubt if that will be mentioned in the final report at all.
What hopefully emerge is there are systemic problems that exist that led to the accident. I really don't want to go into any further detail right now. However, I think jaws will drop when the final report, data plot and CVR are released.
I have seen the data and I can assure you things went wrong prior to the missed approach. There are several issues that, hopefully, will appear in the accident report.
There was no spatial disorientation, at least, there is no evidence to suggest that in the CVR and I doubt if that will be mentioned in the final report at all.
What hopefully emerge is there are systemic problems that exist that led to the accident. I really don't want to go into any further detail right now. However, I think jaws will drop when the final report, data plot and CVR are released.
Spatial disorientation has never been more than just a possible explanation for the facts so far reported. More facts would be welcome to help all of us understand the accident, particularly as you suggest systemic problems may underpin it. Let's hope more information is available soon.
ELAc
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CONF iture,
Re #1, yes that could be true, but before we do so we should make sure we know what the problem really is, what improvement we will achieve and what the quantum of the extra risk we choose to accept is.
Re #2, also true, but the risk lies in those who don't recognize the appropriate time to press said buttons.
ELAC
- You are correct in your assessment, but it could be about time to accept those temporary "extra risks" if you want to improve the overall situation in a near future.
- If a crew is not comfortable with its manual flying during an approach, just press again the 2 or 3 buttons to give back the controls to the airplane.
Re #2, also true, but the risk lies in those who don't recognize the appropriate time to press said buttons.
ELAC
Last edited by ELAC; 23rd Jun 2010 at 20:35.
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The way to do this in a public internet, having privelged information, is to Lead by offering food for thought to the discussion. Else your methods become the subject rather than the message.
Systemic problems and food for thought....
1) Passing the FAF below the hard altitude.
2) Descending well below minimums (busted by 1XX Feet)
3) Improper Go Around procedures
4) Possible improper use of Priority Switch
5) Switching from Managed/Managed to Selected/Selected approach just prior to commencent of the approach.
Please note, these tidbits are in no order. Nor are they all inclusive. There are other issues that will certainly be looked as contributing factors.
I have no dog in this fight. I am not trying to point fingers at anyone one group or group of pilots in this matter. I am merely trying to have people look at this accident from a very simplistic view. When the final report is issued, hopefully, you will be able to see just how simplistic and utterly avoidable this accident was.
Systemic problems and food for thought....
1) Passing the FAF below the hard altitude.
2) Descending well below minimums (busted by 1XX Feet)
3) Improper Go Around procedures
4) Possible improper use of Priority Switch
5) Switching from Managed/Managed to Selected/Selected approach just prior to commencent of the approach.
Please note, these tidbits are in no order. Nor are they all inclusive. There are other issues that will certainly be looked as contributing factors.
I have no dog in this fight. I am not trying to point fingers at anyone one group or group of pilots in this matter. I am merely trying to have people look at this accident from a very simplistic view. When the final report is issued, hopefully, you will be able to see just how simplistic and utterly avoidable this accident was.
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aterpster,
No, that's not particularly new. Scroll back and look at some of the past accidents as I posted to deSitter. For similarities to Turkish in the 80's look at the SAS DC10 in JFK or the Buffalo 707 in Kansas City. For Colgan, the L188 at KC and the China Airlines 747SP bear great similarity. There have always been "a few" accidents of this nature.
As a side note, the initiation of both of these accidents occurred because of a failure of monitoring skill, not manual control skill. Greater practice at manual flying might have improved the quality of monitoring when the a/p is on, as it was in both these cases, but then again possibly not. That's an unproven hypothesis. In any event the failure to monitor was not the final nail in the coffin in either case. Inappropriate stall recovery actions take the blame in both instances, and that is not going to be improved by more hand flying.
It's not a "club" and you haven't been expelled from it aterpster, so how about canning the trucelence. Perhaps though, as a guy who last flew the line 20 years ago you might accept that some things have changed since then in ways you may not have a full appreciation of, and that the perspectives of someone who spends each day up close and personal with the equipment we're discussing bears being considered a bit less dismissively.
Hmm, yeah with RNP AR I suspected that's where you wanted to go. The environment I work in today does have some Dark Ages elements to it, but that would not be the case with some of the previous operations that I've spent time with. I'm thinking that having collected the qualifications to operate these types from 6 different authorities including TC, FAA and CAA and having been hands on with carriers and crews in a number of different countries and cultures might give me a wee bit more insight into how things work in practice than any particular approach qualification.
Regards,
ELAC
PS - We're now doing a disservice to the thread so if you wish to continue the discussion I'll be happy to do so on the thread BOAC has suggested, or by PM. You may yet be surpised on the number of areas where we would share full agreement.
What's new under the Sun is the total ineptness with the Turkish Air and Colgan crews; the obvious lack of basic attitude instrument flying skills.
As a side note, the initiation of both of these accidents occurred because of a failure of monitoring skill, not manual control skill. Greater practice at manual flying might have improved the quality of monitoring when the a/p is on, as it was in both these cases, but then again possibly not. That's an unproven hypothesis. In any event the failure to monitor was not the final nail in the coffin in either case. Inappropriate stall recovery actions take the blame in both instances, and that is not going to be improved by more hand flying.
Quote:
About RNP AR qualification, the answer is no, the regulatory authority that has jurisdiction over my carrier has yet to implement that standard, and as a consequence it is not in use with my company. But then, what does that have to do with the price of tea in China?
It's pertinent because you come across as being a state-of-the-art pilot unlike those of us who have been "expelled from the club." Sounds like your operations today are much like what we did in the Dark Ages.
About RNP AR qualification, the answer is no, the regulatory authority that has jurisdiction over my carrier has yet to implement that standard, and as a consequence it is not in use with my company. But then, what does that have to do with the price of tea in China?
It's pertinent because you come across as being a state-of-the-art pilot unlike those of us who have been "expelled from the club." Sounds like your operations today are much like what we did in the Dark Ages.
Hmm, yeah with RNP AR I suspected that's where you wanted to go. The environment I work in today does have some Dark Ages elements to it, but that would not be the case with some of the previous operations that I've spent time with. I'm thinking that having collected the qualifications to operate these types from 6 different authorities including TC, FAA and CAA and having been hands on with carriers and crews in a number of different countries and cultures might give me a wee bit more insight into how things work in practice than any particular approach qualification.
Regards,
ELAC
PS - We're now doing a disservice to the thread so if you wish to continue the discussion I'll be happy to do so on the thread BOAC has suggested, or by PM. You may yet be surpised on the number of areas where we would share full agreement.
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(Newby posting)
I found this forum a few days after May 12, since a very good friend of mine (Anton Matthee, from Stellenbosch, South Africa) died on this flight, and I needed to support the widow with as many pertinent and (as far as possible) factual data bits related to her husband's untimely death.
I found enough here to be able to tell her it was an unexpected and very fast death, and want to thank you collectively for your dissemination and discussion of the few factoids that were available back then. My conclusion was of some comfort to her, and also to me and other close friends. I can also report that he has been identified, repatriated, and that there is (at least biological) closure on the matter.
The reason for my post is a question: Will this thread remain vigilant for (and ready to discuss) factual news being released on the accident, or has it definitively moved on to policy & procedure discussions? If the former, I'll remain an interested reader, if the latter, I'd like a heads-up to start probing elsewhere. Thanks.
Edit:
Heartbreaking.
I found this forum a few days after May 12, since a very good friend of mine (Anton Matthee, from Stellenbosch, South Africa) died on this flight, and I needed to support the widow with as many pertinent and (as far as possible) factual data bits related to her husband's untimely death.
I found enough here to be able to tell her it was an unexpected and very fast death, and want to thank you collectively for your dissemination and discussion of the few factoids that were available back then. My conclusion was of some comfort to her, and also to me and other close friends. I can also report that he has been identified, repatriated, and that there is (at least biological) closure on the matter.
The reason for my post is a question: Will this thread remain vigilant for (and ready to discuss) factual news being released on the accident, or has it definitively moved on to policy & procedure discussions? If the former, I'll remain an interested reader, if the latter, I'd like a heads-up to start probing elsewhere. Thanks.
Edit:
Originally Posted by Phil Squares
... you will be able to see just how simplistic and utterly avoidable this accident was ...
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Originally Posted by ELAC
Inappropriate stall recovery actions take the blame in both instances, and that is not going to be improved by more hand flying.
I believe you know this already.
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LJ du Toit
Welcome aboard. None of us envy your position, and you certainly deserve our support.
As I'm sure you have recognized by now, this is not always the most gentlemanly (or ladylike) of forums, and at this stage of investigation many theories are propagated. Most have at least some smattering of respectability. But the real value here is the ability of most contributors to see through the haze of politics that can disguise the truth.
Hope you can stick around.
I found this forum a few days after May 12, since a very good friend of mine (Anton Matthee, from Stellenbosch, South Africa) died on this flight, and I needed to support the widow with as many pertinent and (as far as possible) factual data bits related to her husband's untimely death.
As I'm sure you have recognized by now, this is not always the most gentlemanly (or ladylike) of forums, and at this stage of investigation many theories are propagated. Most have at least some smattering of respectability. But the real value here is the ability of most contributors to see through the haze of politics that can disguise the truth.
Hope you can stick around.
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One Outsider,
Agreed, but where is the evidence that preoccupation with the "manipulation of the mechanism" played a role in these accidents? The initiator was a failure of monitoring, it was the autopilot that was doing the manipulation.
The incorrect stall warning recoveries were procedural errors. One was a very deliberate choice to hold a high pitch attitude exacerbating instead of resolving the condition. The other had a 7 second delay in application of TOGA power resultant from both a change of control and an erroneous autothrust mode that retarded power again after it had already been applied by the original PF.
There's nothing there to suggest that the way these stall warning recoveries were accomplished was the result of a "bucket full" situation with too much mental capacity being used for manual manipulation leading to a loss of focus on the desired outcome when the extra ball was tossed in.
ELAC
Whenever manipulation of a mechanism is required to achieve a certain outcome, the manipulation must be second nature so that the focus can be on achieving the desired outcome. If it is not, the focus will be on the manipulation and not on the outcome.
I believe you know this already.
I believe you know this already.
The incorrect stall warning recoveries were procedural errors. One was a very deliberate choice to hold a high pitch attitude exacerbating instead of resolving the condition. The other had a 7 second delay in application of TOGA power resultant from both a change of control and an erroneous autothrust mode that retarded power again after it had already been applied by the original PF.
There's nothing there to suggest that the way these stall warning recoveries were accomplished was the result of a "bucket full" situation with too much mental capacity being used for manual manipulation leading to a loss of focus on the desired outcome when the extra ball was tossed in.
ELAC