AF 447 report out
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The system "heeded" the "omens" perfectly well:
It just didn't fix the issue on this particular aircraft fast enough.
Originally Posted by BEA F-GZCP Final Report (En) P.124
On 24 November 2008, the issue of inconsistent airspeed indications was raised during a meeting between the technical divisions of Air France and Airbus. Air France requested an analysis of the root cause and a technical solution to resolve this problem, and suggested that BF Goodrich probes should be fitted, since their reliability appeared to be greater. Airbus confirmed its analysis and agreed to check the option of replacing the Thales probes with BF Goodrich probes. This point was followed by Air France and Airbus via the implementation of a "dashboard of indicators" approach.
At the end of March 2009, Air France experienced two further events involving the temporary loss of airspeed indication, including the first event on an A330. On 3 April 2009, in light of these two new cases, Air France once again asked Airbus during a technical meeting to find a definitive solution.
On 15 April 2009, Airbus informed Air France of the results of a study conducted by Thales. Airbus stated that the icing phenomenon involving ice crystals was a new phenomenon that was not considered in the development of the Thales C16195BA probe, but that the latter appeared to offer significantly better performance in relation to unreliable airspeed indications at high altitude. Airbus offered Air France an "in-service evaluation" of the C16195BA standard to check the behaviour of the probe under actual conditions.
Air France decided to extend this measure immediately to its entire A330/A340 longhaul fleet, and to replace all the airspeed probes. An internal technical document was drawn up to introduce these changes on 27 April 2009. The modification work on the aircraft was scheduled to begin as soon as the parts were received. On 19 May 2009, based on this decision, the monitoring of these incidents was considered as closed during the RX2 meeting. The first batch of Pitot C16195BA probes arrived at Air France on 26 May 2009, i.e. six days before F-GZCP crashed. The first aircraft was modified on 30 May 2009.
At the end of March 2009, Air France experienced two further events involving the temporary loss of airspeed indication, including the first event on an A330. On 3 April 2009, in light of these two new cases, Air France once again asked Airbus during a technical meeting to find a definitive solution.
On 15 April 2009, Airbus informed Air France of the results of a study conducted by Thales. Airbus stated that the icing phenomenon involving ice crystals was a new phenomenon that was not considered in the development of the Thales C16195BA probe, but that the latter appeared to offer significantly better performance in relation to unreliable airspeed indications at high altitude. Airbus offered Air France an "in-service evaluation" of the C16195BA standard to check the behaviour of the probe under actual conditions.
Air France decided to extend this measure immediately to its entire A330/A340 longhaul fleet, and to replace all the airspeed probes. An internal technical document was drawn up to introduce these changes on 27 April 2009. The modification work on the aircraft was scheduled to begin as soon as the parts were received. On 19 May 2009, based on this decision, the monitoring of these incidents was considered as closed during the RX2 meeting. The first batch of Pitot C16195BA probes arrived at Air France on 26 May 2009, i.e. six days before F-GZCP crashed. The first aircraft was modified on 30 May 2009.
At the time of the accident, F-GZCP was fitted with the original C16195AA probes.
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Originally Posted by DozyWannabe
The system "heeded" the "omens" perfectly well:
It just didn't fix the issue on this particular aircraft fast enough.
It just didn't fix the issue on this particular aircraft fast enough.
Either the system heeded the omen and fixed the problem, or it didn't. We have 228 graves on exhibit to show that the problem wasn't fixed.
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Originally Posted by BEA F-GZCP Final Report (En) P.124
On 24 November 2008, the issue of inconsistent airspeed indications was raised during a meeting between the technical divisions of Air France and Airbus
On 24 November 2008, the issue of inconsistent airspeed indications was raised during a meeting between the technical divisions of Air France and Airbus
Really ? that's in 2008 that this problem was discovered and raised in safety discussion ?
Seem's that the BEA have a limited or short memory ....
December 1995: TFU 34.13.00.005 (Appendix 1). Airbus made the observation of the lack of
certification on the Pitot probes in the presence of ice crystals and launches development
probe Goodrich P / N 0851HL
certification on the Pitot probes in the presence of ice crystals and launches development
probe Goodrich P / N 0851HL
Augustus 1996 : NTSB recommendation : Revise the icing certification testing regulation
to ensure that airplanes are properly tested for all conditions in which they are authorized to operate,
or are otherwise shown to be capable of safe flight into such conditions. If safe operations cannot be
demonstrated by the manufacturer, operational limitations should be imposed to prohibit flight in
such conditions and flight crews should be provided with the means to positively determine when
they are in icing conditions that exceed the limits for aircraft certification. (Class II, Priority Action)
(A‐96‐56)
to ensure that airplanes are properly tested for all conditions in which they are authorized to operate,
or are otherwise shown to be capable of safe flight into such conditions. If safe operations cannot be
demonstrated by the manufacturer, operational limitations should be imposed to prohibit flight in
such conditions and flight crews should be provided with the means to positively determine when
they are in icing conditions that exceed the limits for aircraft certification. (Class II, Priority Action)
(A‐96‐56)
January 1999: The BFU recommends changing the certification standards of the Pitot probes
(Annex 13).
(Annex 13).
Last edited by jcjeant; 15th Aug 2012 at 19:42.
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@jcj - as discussed, completely different type of both pitot tube and aircraft. The 1995 issue was with Rosemount tubes on older types.
July 2002: In the OIT 999.0068/02/VHR SE (Annex 4), Airbus made the observation of defects
probe Thales (formerly Sextant) P / N C16195AA.
probe Thales (formerly Sextant) P / N C16195AA.
September 2007: The EASA made the finding of the lack of certification of the Pitot probes (Appendix
6)
6)
And ...
On 24 November 2008, the issue of inconsistent airspeed indications was raised during a meeting between the technical divisions of Air France and Airbus
Last edited by jcjeant; 15th Aug 2012 at 19:52.
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Near Miss Aricle Link
TTex600
Here is a link to the full wired scinece article by Ben Paynter
Close Calls Are Near Disasters, Not Lucky Breaks | Wired Science | Wired.com
Here is a link to the full wired scinece article by Ben Paynter
Close Calls Are Near Disasters, Not Lucky Breaks | Wired Science | Wired.com
jcjeant, we might assume that BEA are intelligent enough to understand the difficulties and limitations of a systemic investigation; and any findings might not fit the ICAO format. The accident can be, and should be viewed as systemic; the events emerged from within a particular combination of circumstances.
As TTex600 notes, previous incidents were recovered safely – we must learn from these. Perhaps one aspect is that it wasn’t the successful outcomes which were important, which were used to justify continued operation; but the assessment of how much the safety margins had been eroded, - the training and ability of all crews, in all conditions (hindsight).
The final report is ‘interestingly’ formal and may have been crafted with wider aspects of flight safety in mind. It is a challenge to the industry, to consider what could or should be done generically (systemically) to improve safety.
The report avoids use of overt ‘error’, instead considering the many factors which could influence human behaviour. In several ways this invites a change or strengthening of the ‘new view of human error’.
Based on the apparent divide in this forum, even amongst the identifiable professionals, the industry has a long way to go before acceptance the ‘new (systemic) view’, which appears to be essential as the majority of our industry now resides in the ‘highly reliable’ category. This shortfall might also reflect the standard of HF and CRM training, but also the views of operator management and regulators, all possible contributors in this accident.
How to be safe by looking at what goes right instead of what goes wrong.
For factors limiting learning; see Fundamental on Situational Surprise.
As TTex600 notes, previous incidents were recovered safely – we must learn from these. Perhaps one aspect is that it wasn’t the successful outcomes which were important, which were used to justify continued operation; but the assessment of how much the safety margins had been eroded, - the training and ability of all crews, in all conditions (hindsight).
The final report is ‘interestingly’ formal and may have been crafted with wider aspects of flight safety in mind. It is a challenge to the industry, to consider what could or should be done generically (systemically) to improve safety.
The report avoids use of overt ‘error’, instead considering the many factors which could influence human behaviour. In several ways this invites a change or strengthening of the ‘new view of human error’.
Based on the apparent divide in this forum, even amongst the identifiable professionals, the industry has a long way to go before acceptance the ‘new (systemic) view’, which appears to be essential as the majority of our industry now resides in the ‘highly reliable’ category. This shortfall might also reflect the standard of HF and CRM training, but also the views of operator management and regulators, all possible contributors in this accident.
How to be safe by looking at what goes right instead of what goes wrong.
For factors limiting learning; see Fundamental on Situational Surprise.
Last edited by alf5071h; 15th Aug 2012 at 20:16.
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The report avoids use of overt ‘error’, instead considering the many factors which could influence human behaviour
In particular, States must start an investigation in case of a civil aviation accident or serious incident on their territory. It is specified that "The sole objective of the investigation of an accident or incident shall be the prevention of accidents and incidents" and that "It is not the purpose of this activity to apportion blame or liability"
On the other hand it would have been interesting (for public information) that BEA put in annex the entire history of pitot tube (since at least 1995)
The pitot tube is an important element in this accident
This would give an insight into how are functioning the official bodies responsible for air safety
In January 1999, due to a serious incident in Frankfurt April 5, 1998, the BFU (German) recommended changing certification standards Pitot probes
(Annex 13), the standards may be the cause of accidents.
01/99 The specification for the Pitot tubes should be changed so as
to allow unrestricted flight operations in heavy rain and under severe
icing conditions.
This safety recommendation was ignored.
Standards certification probes Pitot were modified by EASA after the accident in August 2009 (Appendix 50).
Note: The BEA has done it again this recommendation in its second interim report.
It confirms its importance
(Annex 13), the standards may be the cause of accidents.
01/99 The specification for the Pitot tubes should be changed so as
to allow unrestricted flight operations in heavy rain and under severe
icing conditions.
This safety recommendation was ignored.
Standards certification probes Pitot were modified by EASA after the accident in August 2009 (Appendix 50).
Note: The BEA has done it again this recommendation in its second interim report.
It confirms its importance
Last edited by jcjeant; 15th Aug 2012 at 21:58.
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A "near miss", probability wise, is not a success. They are indicators of failure. If a flaw is systemic, it requires only a small twist of fate for the next incident to result in disaster. "Rather than celebrate then ignoring close calls, we should be learning from them and doing our best to prevent their recurrence." ......"most accident investigations work backward to determine the cause. A more effective way to curtail disasters is to get better at spotting the near miss"
In context of AF447, and considering the continued emphasis of some board participants on previously successful near misses (thirty something UAS incidents caused by pitot ice), I suggest that we begin to view those previous A330 UAS incidents as omens. Omens that the system failed to heed.
Additionally, AF, Airbus, EASA and other regulatory agencies discussed the pitot issue during various meetings. EASA interviewed pilots that experienced pitot clogging resulting in UAS situation. The interviewed pilots responses varied from being ho-hum to a non-incident although they reported it as being unusual. Other pilots never reported Pitot/UAS incidents at all. This feedback lead to EASA not issuing an immediate change out of Thales for Goodrich pitots.
Be Forewarned: The problem with pitots icing still exists, it can bite you at any time, there is no magical solution and there may not be in our lifetimes. And then too, the pitots themselves may not be entirely the problem. The location of the pitots in relationship to the airstream at their location could be a factor: Per Airbus, "Depending on the probe design and aircraft installation these installation effects can lead to the Liquid Water Content (LWC) at the probe location several times greater than the free-stream conditions." This could be true for ice crystals as well. Not much is actually known about ice crystal sizes, shapes, distributions and concentrations at high altitudes. Test chambers can only do so much without specific knowledge that would be variable at best, think snowflake differences. So now - the pilots:
Recognizing UAS can and will occur, every pilot receives some training regarding UAS and what to do should it happen. In the instance of AF, there was prior training and emphasis to the point of issuing every flight crew a handout notification of recent AF UAS occurrences and reminding them of what to do upon experience of UAS.
For all the the 30+crews and probably many, many more, it wasn't good luck, an indication of failure or an omen, it was a success due to good aviating.
Enough said....
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Yep, the AF447 crew received UAS training. But somewhere buried in the reports, it mentioned that said training was low altitude and that they never received any training for UAS or stall at cruise. The low alt/take off scenario has a memory item. 15 degrees nose up. Ring any bells?
Thanks jcjeant.
In this instance, pitots are a ‘local’ technical problem ( Fundamental on Situational Surprise, para 3.2. ), and as you note, focus of attention on these would overlook an important aspect of ‘learning’ as to why the initial recommendation was ignored.
Opposed to ‘ignored’, I suspect that there was consideration and justification (risk assessment) as to why modifications or other mitigating action was not required at that time (Turbine D). Thus an important lesson might be to reconsider the process of risk assessment, by whom, and the assumptions made. Also, if BFU was really concerned, why wasn’t the recommendation’s rejection pursued?
Many of these issues have been discussed individually, but if reconsidered with a wider remit for safety and not just by ‘official bodies’, then we might identify some really important lessons, and aspects which can be improved.
For example, ‘officialdom’ is not responsible for safety, we all are. Thus why weren’t all of the blinding obvious issues in hindsight identified before the accident, or at least after the preceding incidents? If we could answer that we might be safer, but the answer involves understanding ourselves.
How can everyone in the industry improve their ability to generate foresight and act?
Do we really think about safety as we should; do we think?
Not always, because we are human, but we could do better if we thought about it.
In this instance, pitots are a ‘local’ technical problem ( Fundamental on Situational Surprise, para 3.2. ), and as you note, focus of attention on these would overlook an important aspect of ‘learning’ as to why the initial recommendation was ignored.
Opposed to ‘ignored’, I suspect that there was consideration and justification (risk assessment) as to why modifications or other mitigating action was not required at that time (Turbine D). Thus an important lesson might be to reconsider the process of risk assessment, by whom, and the assumptions made. Also, if BFU was really concerned, why wasn’t the recommendation’s rejection pursued?
Many of these issues have been discussed individually, but if reconsidered with a wider remit for safety and not just by ‘official bodies’, then we might identify some really important lessons, and aspects which can be improved.
For example, ‘officialdom’ is not responsible for safety, we all are. Thus why weren’t all of the blinding obvious issues in hindsight identified before the accident, or at least after the preceding incidents? If we could answer that we might be safer, but the answer involves understanding ourselves.
How can everyone in the industry improve their ability to generate foresight and act?
Do we really think about safety as we should; do we think?
Not always, because we are human, but we could do better if we thought about it.
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alf5071h
"Do we really think about safety as we should; do we think?
Not always, because we are human, but we could do better if we thought about it.
We would not be discussing this, if some off the reservation AF employee had not leaked ACARS. Neither would the wreck have been discovered....
Make no mistake, full damage control was applied, and missed the mark, completely. Subtract popular opinion and continued discussion, the final search would never have been mounted......
So to answer the question, we think about it when we have the facts, and are not misled and lied to by two bit managers and "Presidents".
Credit the Brasilians, and those who would not succumb to standard drill bs in the media...
imo
"Do we really think about safety as we should; do we think?
Not always, because we are human, but we could do better if we thought about it.
We would not be discussing this, if some off the reservation AF employee had not leaked ACARS. Neither would the wreck have been discovered....
Make no mistake, full damage control was applied, and missed the mark, completely. Subtract popular opinion and continued discussion, the final search would never have been mounted......
So to answer the question, we think about it when we have the facts, and are not misled and lied to by two bit managers and "Presidents".
Credit the Brasilians, and those who would not succumb to standard drill bs in the media...
imo
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But somewhere buried in the reports, it mentioned that said training was low altitude and that they never received any training for UAS or stall at cruise.
The low alt/take off scenario has a memory item. 15 degrees nose up. Ring any bells?
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if some off the reservation AF employee had not leaked ACARS
Experts (other than the BEA) have early conduct an investigation and their findings was not the least (some members of PPrunes are not strangers to those discoveries)
Who was the AF "Assange" .. probably we'll never know ...
Last edited by jcjeant; 16th Aug 2012 at 02:39.
Originally Posted by TTex600
Why bother checking your posts if you can't tell the truth on your personal page? Are you not really a flight sim fan?
Your Honor, this pertains because it speaks to the credibility of the witness.
Your Honor, this pertains because it speaks to the credibility of the witness.
Originally Posted by TTex600
Why would one place information on their personal info that is "unbelievable"?
But I submit that (some level of) decorum and respect is required before there can be a credible discussion.
Originally Posted by Organfreak
Why the Airbus Must Never Be Criticized, Upon Pain of Ridicule.
Originally Posted by Retired F4
It was flightpath stable in the pitch axis, roll axis being in roll direct.
I find insistence on discussing details before essentials are dealt with interesting form psychological PoW, slightly amusing and not particularly helpful in discussion.
Originally Posted by Retired F4
Not irrelevant in context to wrong statements like DW´s post.
Originally Posted by Retired F4
In the real world of air transport flying LOC´s are not common and recognition of high altitude LOC seems to be dubious, due to never trained (only in low altitude) and never talked about.
Originally Posted by BEA
it is clear that almost all the crews that heard the stall warning considered it to be surprising and irrelevant.
Originally Posted by TTex600
In the August 2012 issue of Wired magazine, author Ben Paynter penned an article named, "The Fire Next Time". "The Fire Next Time"s discusses the paradox of the "close call".
Originally Posted by alf5071h
The report avoids use of overt ‘error’,
Originally Posted by TTex600
The low alt/take off scenario has a memory item. 15 degrees nose up. Ring any bells?
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Originally Posted by Clandestino
There are many a LoCs that are recovered before ground impact so they don't involve untimely dead therefore not causing emotions to run high. Consequently they seldom make it to second page on the PPRuNe thread, if they get discussed at all.
as discussed, completely different type of both pitot tube and aircraft. The 1995 issue was with Rosemount tubes on older types.
pithy one liner that says nothing in context, it might be usefull to have
some tech discussion on the actual point being made. Don't want to appear
offensive, but over sensitivity and constant refutations only add to the
noise.
What he was implying was that the general problem had been known about in
1995. No pointing fingers etc.
Having said that, this issue looks like one of complacency and regulatory
failure to take the problem seriously enough, probably with pressure from
the airline industry.
From what I can see, airbus have been working on this for years, but can
only make recommendations. They have no power to impose mandatory changes...
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Always remember
- weather radar in 320NM range
- 19 kts below VLS
- "The pilot flying noticed the decreasing speed and selected Mach 0.93,"
- "the vertical speed increases through 5700 feet per minute, the crew does not notice the excessive climb rate, engine N1 is at 100%"
Yes this wasn't AF447, two years later an A340, same company.
Chilling....
Incident: Air France A343 near Guadeloupe on Jul 22nd 2011, rapid climb and approach to stall in upset
An Air France Airbus Axxx-300, registration F-Gxxx performing flight AF-4xx from xxx to Paris Charles de Gaulle (France), was enroute at FL350 about 145nm northeast of Point xxx in night and instrument meteorological conditions at around 01:11Z when the crew received an overspeed alert, the autopilot disconnected, the crew observed the indicated airspeeds had increased to 0.88 mach (MMO 0.86 mach) and 304 knots, the aircraft gradually increased its pitch attitude to 11 degrees and climbed with up to 5000 feet/minute up to FL380, reaching FL380 at 0.66 mach/ 205 KIAS - stall speed was computed at 202 KIAS - before the pitch attitude decreased again
- 19 kts below VLS
- "The pilot flying noticed the decreasing speed and selected Mach 0.93,"
- "the vertical speed increases through 5700 feet per minute, the crew does not notice the excessive climb rate, engine N1 is at 100%"
Yes this wasn't AF447, two years later an A340, same company.
Chilling....
Incident: Air France A343 near Guadeloupe on Jul 22nd 2011, rapid climb and approach to stall in upset
Last edited by hetfield; 16th Aug 2012 at 11:13.
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http://www.pprune.org/rumours-news/4...ml#post7334399
Pitot tube issues with occasional UAS problems are not specific to Airbus types and never have been.
Also, all this talk of an "AF Assange" who leaked a record that the French authorities would have preferred stayed hidden and swept the issue under the carpet is in very poor taste and deserves no more credence than the crackpot "WTC inside job" suggestions.