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There are warnings on both PFD's if the two PFD's differentiate (PIT, ROL, HDG). Those warnings were absent since the two PFD's went into declutter mode, because of the unusual "false" attitude on PFD1.
The simulator the 2 pilots regularly trained on, had those warnings present even in declutter mode. But not the real airplane, manufacturer was criticized by SHK.
The probable cause why they didn't check the standby attitude indicator, was that they were subjected to - 1G to +3G & many auditory and visual warnings.
Google translate from the final report by SHK:
"That none of the pilots of the situation verbally referring to standby attitude indicator can be explained by the two experiencing a complex situation because of the varying G loads and a great amount auditory and visual warnings. This has probably contributed further to cognitively
tunnel vision and focus on each PFD."
It's easy to be a hot-shot pilot in front your computer! But if you read the whole report it's more understandable why it happened.
The simulator the 2 pilots regularly trained on, had those warnings present even in declutter mode. But not the real airplane, manufacturer was criticized by SHK.
The probable cause why they didn't check the standby attitude indicator, was that they were subjected to - 1G to +3G & many auditory and visual warnings.
Google translate from the final report by SHK:
"That none of the pilots of the situation verbally referring to standby attitude indicator can be explained by the two experiencing a complex situation because of the varying G loads and a great amount auditory and visual warnings. This has probably contributed further to cognitively
tunnel vision and focus on each PFD."
It's easy to be a hot-shot pilot in front your computer! But if you read the whole report it's more understandable why it happened.
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Exactly. Hearing what the fault was first and then knowing exactly what to do is not the same as an instinctive reaction to an unusual presentation on your PFD. I suspect most would at minimum, make some kid of significant input to an unusual attitude suddenly presenting itself.
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Always happy to see the could-never-happen-to-me-itis in post-occurrence threads.
Hindsight is always 20/20; after every accident you can say oh all they had to do was x, etc...
The rational brain is suppressed in situations like these.
The only way to deal with them is frequent high-stress training and accumulating as much of theoretical knowledge as possible.
Take a look at this (what they were seeing):
© Swedish Accident Investigation Authority | Creative Commons Attribution 2.5 Sweden
Alarms screaming at you, negative G's hitting you, you don't know what's happening, adrenaline rushing through your body with your body clock asleep, no outside visibility, you're disoriented; yes, I can definitely see them losing it. At that point it would've been difficult to recover. I agree the initial reaction was not supposed to be so swift as the flight was smooth and stable but what do they teach us: never trust your senses in LVC, your ADI is your life. And this instrumental piece of equipment, which was guiding the pilot his whole life without error and which had earned his deep trust, ended up betraying him.
To include the (only) two recommendations:
How about instigating additional and more frequent training including curricula concerning human performance in distress, communication, crosscheck, unusual attitude recovery, high altitude flight dynamics...
When you have a 'STALL, STALL' warning yelling at you for a full minute and you still don't figure you're in a stall, we have a different set of problems to solve.
It's easy to shove it on the two fellows who can't defend themselves and call it a day, but remember, a fish rots from the head down.
The next time you load up and takeoff, know that the fish is still rotting and the clock is ticking. 'Safe flight.
Hindsight is always 20/20; after every accident you can say oh all they had to do was x, etc...
The rational brain is suppressed in situations like these.
The only way to deal with them is frequent high-stress training and accumulating as much of theoretical knowledge as possible.
Take a look at this (what they were seeing):
© Swedish Accident Investigation Authority | Creative Commons Attribution 2.5 Sweden
Alarms screaming at you, negative G's hitting you, you don't know what's happening, adrenaline rushing through your body with your body clock asleep, no outside visibility, you're disoriented; yes, I can definitely see them losing it. At that point it would've been difficult to recover. I agree the initial reaction was not supposed to be so swift as the flight was smooth and stable but what do they teach us: never trust your senses in LVC, your ADI is your life. And this instrumental piece of equipment, which was guiding the pilot his whole life without error and which had earned his deep trust, ended up betraying him.
To include the (only) two recommendations:
Ensure that the design criteria of PFD units are improved in such a way that pertinent cautions are not removed during unusual attitude or declutter modes.
Ensure that a general system of initial standard calls for the handling of abnormal and emergency procedures and also for unusual and unexpected situations is implemented throughout the commercial air transport industry.
It's easy to shove it on the two fellows who can't defend themselves and call it a day, but remember, a fish rots from the head down.
The next time you load up and takeoff, know that the fish is still rotting and the clock is ticking. 'Safe flight.
Last edited by Wrist Watch; 13th Dec 2016 at 12:20.
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"the fact
that there was no training method for effective communication in an
unexpected or abnormal situation and that the crew therefore had not
practised this contributed to the crew not being able to jointly identify
the problem in time"
The operator has to be the main culprit here, not having a training standard that at least addresses this BASIC CRM issue.
Any "normal" fault detection should at least be confirmed by 2 or more parameters, and cross referenced between the crew.
Both crew was relative "low experienced" guys, however in my opinion the operator does not seem to have had a sufficient high standard of training, leading to an event like this being allowed to happen. Basic CRM and Error fault management seems to have been completely lacking.
that there was no training method for effective communication in an
unexpected or abnormal situation and that the crew therefore had not
practised this contributed to the crew not being able to jointly identify
the problem in time"
The operator has to be the main culprit here, not having a training standard that at least addresses this BASIC CRM issue.
Any "normal" fault detection should at least be confirmed by 2 or more parameters, and cross referenced between the crew.
Both crew was relative "low experienced" guys, however in my opinion the operator does not seem to have had a sufficient high standard of training, leading to an event like this being allowed to happen. Basic CRM and Error fault management seems to have been completely lacking.
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Wrist Watch :
Absolutely. Fully agree with you .
After an accident ,Humans and pilots in particular always tend to (and like to) go into a safe protection mode : "this will not have happened to me " . We all have this .
Writing about it here brings nothing except perhaps make themselves feeling better.
We have numerous human factors studies explaining you the "why" and "what" happens in your body/brain when faced into a extreme highly stressed situation . Listening to multiple audio warnings and blinking warning lights rather add to the confusion/stress rather than helping to solve the problem . So I always get a bit annoyed when I read that : " they had a stall warning and did not react as they should have ...etc..."
Likewise, focusing on a single wrong display in isolation and being mind set in correcting it, disregarding other options, is a well known phenomena, known to be aggravated when occurring in middle of the night.
The 3 Miles Island nuclear accident report covers it quite well.
More recently the AF447 BEA report mentions it as well.
What make some posting here so sure they would not be subject to the same human factors ?
Always happy to see could-never-happen-to-me-itis in post-occurrence threads.
Hindsight is always 20/20; after every accident you can say oh all they had to do was x, etc...
The rational brain is suppressed in situations like these.
Hindsight is always 20/20; after every accident you can say oh all they had to do was x, etc...
The rational brain is suppressed in situations like these.
After an accident ,Humans and pilots in particular always tend to (and like to) go into a safe protection mode : "this will not have happened to me " . We all have this .
Writing about it here brings nothing except perhaps make themselves feeling better.
We have numerous human factors studies explaining you the "why" and "what" happens in your body/brain when faced into a extreme highly stressed situation . Listening to multiple audio warnings and blinking warning lights rather add to the confusion/stress rather than helping to solve the problem . So I always get a bit annoyed when I read that : " they had a stall warning and did not react as they should have ...etc..."
Likewise, focusing on a single wrong display in isolation and being mind set in correcting it, disregarding other options, is a well known phenomena, known to be aggravated when occurring in middle of the night.
The 3 Miles Island nuclear accident report covers it quite well.
More recently the AF447 BEA report mentions it as well.
What make some posting here so sure they would not be subject to the same human factors ?
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The fact that it took 80 seconds from flying a fully serviceable aircraft, until it was all over, in itself is a chilling factor!
And it's true I believe, it could happen to us all, if the Swiss Cheese holes lines up correctly, it's easy to be keyboard experts. Let's not mention the F or S word, because of course nobody wants to ever acknowledge that.
And it's true I believe, it could happen to us all, if the Swiss Cheese holes lines up correctly, it's easy to be keyboard experts. Let's not mention the F or S word, because of course nobody wants to ever acknowledge that.
Yes, a very sad event. It is disappointing that these guys were not effectively trained to a standard that is required to operate the aeroplane at the safety factors required by its certification. Sad, and a hard lesson for others to learn from!
One thing to keep in mind that as much as we'd like to think otherwise, all humans are NOT created equal. We have people with above average skills and cognitive abilities, and people below average. The top 75 percentile will pass any exam designed for the average, the pilot profession is no different. Automation, SOPs and CRM have made enormous advances towards ensuring that the real-life performance of those with above and below average skills are not that far apart anymore. However there always be the odd unexpected situation where superior skills save the day (Sully) and below average skills lose it (AF or this one).
The direct cause in this case was the PF reacting subconsciously to one piece of information, which was seeing a big and increasing piece of blue of the PFD, no doubt the result of many hours of training and conditioning to follow the ADI regardless any sensory illusions. It would have required that extra touch of superior skills given the circumstances to grasp that if speed, altitude and power setting did not change, the indication must be false.
Given the rarity and unforseeable nature of such failures, it is very difficult to effectively train for them, as by their very nature the required action goes contrary to what one was prmarily trained to do. On the other hand, I'm sure everyone who have read the report will sit on their hands for a few seconds in a similar situation. It is a matter of learning from and avoiding other's mistakes.
The direct cause in this case was the PF reacting subconsciously to one piece of information, which was seeing a big and increasing piece of blue of the PFD, no doubt the result of many hours of training and conditioning to follow the ADI regardless any sensory illusions. It would have required that extra touch of superior skills given the circumstances to grasp that if speed, altitude and power setting did not change, the indication must be false.
Given the rarity and unforseeable nature of such failures, it is very difficult to effectively train for them, as by their very nature the required action goes contrary to what one was prmarily trained to do. On the other hand, I'm sure everyone who have read the report will sit on their hands for a few seconds in a similar situation. It is a matter of learning from and avoiding other's mistakes.
Last edited by andrasz; 13th Dec 2016 at 10:19.
IMO, to handle the situation in this event only required training to be able to perform at the minimum standard of skill for being qualified to operate this aeroplane. This event did not require non-standard superior skills to resolve safely, just the correct proceedures! INU failure or Instrument comparitor warnings are not rare or "unforseeable" failures, I have experienced several, including one at night IMC after T/O as PF, and they will continue to happen.
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The direct cause in this case was the PF reacting subconsciously to one piece of information, which was seeing a big and increasing piece of blue of the PFD, no doubt the result of many hours of training and conditioning to follow the ADI regardless any sensory illusions.
Even if fully awake he may have had the sensation of having nodded off for a bit so would be less likely to suspect a technical fault.
Anyone who has ever had a close call (or worse) with falling asleep while driving knows the feeling...
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Extract from the ACCIDENT REPORT:
"According to the aeroplane’s manufacturer,
the autopilot was most likely automatically disconnected due to
differences in the pitch servo commands. The aural warning remained
active for the next 18 seconds."
There were three pilots on board, PF, PM and AP. Once the one who did all the work decided to quit the job, the other two could not handle the situation. I put it down to yet another case of total capitulation to automation.
"According to the aeroplane’s manufacturer,
the autopilot was most likely automatically disconnected due to
differences in the pitch servo commands. The aural warning remained
active for the next 18 seconds."
There were three pilots on board, PF, PM and AP. Once the one who did all the work decided to quit the job, the other two could not handle the situation. I put it down to yet another case of total capitulation to automation.
Even if fully awake he may have had the sensation of having nodded off for a bit...
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andrasz:
Thanks for correction, have not had time to read full report.
May still be partly a 'my fault? technical fault?' decision with known distraction pushing the 'my fault' branch.
Of course even if 'my fault' the correct action is not necessarily immediate extreme corrective action in the same way that swerving to get back on the road is much more dangerous than the initial drifting off.
As others have pointed out it is much easier to see all of this from a calm place in front of a keyboard.
They were doing the approach briefing, so this is not likely.
May still be partly a 'my fault? technical fault?' decision with known distraction pushing the 'my fault' branch.
Of course even if 'my fault' the correct action is not necessarily immediate extreme corrective action in the same way that swerving to get back on the road is much more dangerous than the initial drifting off.
As others have pointed out it is much easier to see all of this from a calm place in front of a keyboard.
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Some real hero pilots here sat typing from the comfort of their laptop keyboards...
Unless you have worked for the operator then you know Jack about the training so please learn a little respect.
The crews that WA have are very good stick and rudder pilots, this event could have happened to anyone...in the middle of the night half asleep at the controls it's a different storey than sitting in your armchair in front of a keyboard ....
Unless you have worked for the operator then you know Jack about the training so please learn a little respect.
The crews that WA have are very good stick and rudder pilots, this event could have happened to anyone...in the middle of the night half asleep at the controls it's a different storey than sitting in your armchair in front of a keyboard ....
+1 Livesinafield.
A few have andrasz. Brave person to put up his hand say couldn't happen to me.
There is nothing new under the sun, for those who wish to criticise rather than understand, some previous accidents brought about for exactly the same reasons.
Korean Air Cargo Flight 8509 - Boeing 747, Stansted
Air India Flight 855 - Boeing 747, Bombay
Copa Airlines Flight 201 - Boeing 737, Panama to Cali
Possibilities
Pan Am Flight 816 - Boeing 707, Papeete
Viasa Flight 897 - DC-8, Portugal
I really wonder how many would have fallen for the trap under similar circumstances
There is nothing new under the sun, for those who wish to criticise rather than understand, some previous accidents brought about for exactly the same reasons.
Korean Air Cargo Flight 8509 - Boeing 747, Stansted
Air India Flight 855 - Boeing 747, Bombay
Copa Airlines Flight 201 - Boeing 737, Panama to Cali
Possibilities
Pan Am Flight 816 - Boeing 707, Papeete
Viasa Flight 897 - DC-8, Portugal
At every SIM we always have to do an EFATO, a OEI ILS to a go-around and a OEI NPA to land.
In the light of recent accidents, I think that two other mandatory elements should be added to every SIM from now on:
1. Unusual attitude recovery.
2. Primary instrument failure, identification and recovery.
Pilots should of course be able to fly manually. (I have flown Southampton to Prague with no autopilot - and it is possible, but very tiring, keeping to +/- 200' for 2 and a half hours). However, there is no getting away from the fact that skills become rusty if not used. In addition, some situations such as AF447 have never been seen by most pilots. (see my post #1119 in the AF447 number 12 thread).
It is all very well writing words on a page in the FCOM/FCTM about how to deal with a problem, but another prospect entirely to recognise and deal with a possibly complex, confusing problem, with no external cues, no previous practice and no warning.
If you showed a concert violinist a piece of Stephane Grapelli music, (jazz violin), and let them read it as much as they wanted, but did not allow them to play or practice it even once; how would it sound the first time they were asked to actually play it? Perfect, or awkward and stilting? Being different from the concert music they were used to, they might not initially be able to play it at all.
In reality of course, the concert violinist would practice the music on their violin over and over again at home before performing it, but we cannot take our airplane home, or use the SIM to practice, and yet we are expected to be able to recognise and react correctly to every possible situation, even if we have never experienced it at all.
In the light of recent accidents, I think that two other mandatory elements should be added to every SIM from now on:
1. Unusual attitude recovery.
2. Primary instrument failure, identification and recovery.
Pilots should of course be able to fly manually. (I have flown Southampton to Prague with no autopilot - and it is possible, but very tiring, keeping to +/- 200' for 2 and a half hours). However, there is no getting away from the fact that skills become rusty if not used. In addition, some situations such as AF447 have never been seen by most pilots. (see my post #1119 in the AF447 number 12 thread).
It is all very well writing words on a page in the FCOM/FCTM about how to deal with a problem, but another prospect entirely to recognise and deal with a possibly complex, confusing problem, with no external cues, no previous practice and no warning.
If you showed a concert violinist a piece of Stephane Grapelli music, (jazz violin), and let them read it as much as they wanted, but did not allow them to play or practice it even once; how would it sound the first time they were asked to actually play it? Perfect, or awkward and stilting? Being different from the concert music they were used to, they might not initially be able to play it at all.
In reality of course, the concert violinist would practice the music on their violin over and over again at home before performing it, but we cannot take our airplane home, or use the SIM to practice, and yet we are expected to be able to recognise and react correctly to every possible situation, even if we have never experienced it at all.
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Several posters referring to keyboard warriors as in suggesting that nobody could have survived an instrument failure and everybody would have died in the same scenario.
This scenario has been along for year: One side goes to, look at the 2 other attitude instruments and compare. Then fly.
Had it happened at night over South America in a B-767.
The secret to survival in this business is to learn from other's mistakes, not just your own. Many similar accidents have happened in the past, hence quite a few companies practice this in the simulator as well as unusual attitude recovery.
It can be confusing, but that is what we train for and get paid for, the good, the bad and the ugly.
This malfunction was very survivable: Compare instruments, rignt side is good: "you got it, you fly it".
This scenario has been along for year: One side goes to
, look at the 2 other attitude instruments and compare. Then fly.Had it happened at night over South America in a B-767.
The secret to survival in this business is to learn from other's mistakes, not just your own. Many similar accidents have happened in the past, hence quite a few companies practice this in the simulator as well as unusual attitude recovery.
It can be confusing, but that is what we train for and get paid for, the good, the bad and the ugly.
This malfunction was very survivable: Compare instruments, rignt side is good: "you got it, you fly it".
The report gives a comprehensive overview of the limitations of human performance, but then by inference, cites the human as a cause by requiring more procedures and training.
More callouts and procedures are unlikely to be effective, particularly in situations where human mental resources are minimal and also because hearing degrades before the other senses.
Many (most) LoC accidents involve misunderstanding a complex situation, and based on this, inappropriate action results in upset conditions; the aircraft were not 'upset' to begin with. Also, each crew member's understanding appeared to differ such that it was impossible to communicate helpful information, at least until the event progressed, often to the point on no recovery.
Because of the human limits we should not expect to see any cross monitoring or CRM in this type of accident. This is an important safety issue particularly as the industry increasingly relies on these safety aspects, in extreme situations like in this accident they may be unavailable.
We cannot expect the humans to cover for system failures in remote or confusing situations. The reliability of modern technology is now so good that when it cannot function (extremely remote), neither can the human. Furthermore, because it is difficult to identify the circumstances and contributions associated with 'extremely remote' events beforehand, it is unlikely that we can provide targeted training; and why train for the last accident which may have no relationship with the next one (excepting the need for improved awareness and surprise management).
The industry should also consider other less obvious factors which could influence pilot behaviour. E.g. how is upset recovery training taught, has the industry over promoted quick reactions to make a nose-down control input, what scenarios are trained in the simulator.
These 'minor', apparently inconsequential contributions could be disregarded, but in extreme circumstance they may be a significant, although not an immediate apparent aspect. The industry has to be aware of 'Meldrew moments' * "I don't believe it'.
This is similar to citing human error as a cause, which should trigger the need to look deeper in the accident; thus any potential contribution judged "I don't believe it ...' should be reconsidered, look deeper for underlying assumptions associated with a less obvious contribution.
* 'Meldrew moments' (MM) from a British tv comedy involving the catchphrase "I don't believe it'.
More callouts and procedures are unlikely to be effective, particularly in situations where human mental resources are minimal and also because hearing degrades before the other senses.
Many (most) LoC accidents involve misunderstanding a complex situation, and based on this, inappropriate action results in upset conditions; the aircraft were not 'upset' to begin with. Also, each crew member's understanding appeared to differ such that it was impossible to communicate helpful information, at least until the event progressed, often to the point on no recovery.
Because of the human limits we should not expect to see any cross monitoring or CRM in this type of accident. This is an important safety issue particularly as the industry increasingly relies on these safety aspects, in extreme situations like in this accident they may be unavailable.
We cannot expect the humans to cover for system failures in remote or confusing situations. The reliability of modern technology is now so good that when it cannot function (extremely remote), neither can the human. Furthermore, because it is difficult to identify the circumstances and contributions associated with 'extremely remote' events beforehand, it is unlikely that we can provide targeted training; and why train for the last accident which may have no relationship with the next one (excepting the need for improved awareness and surprise management).
The industry should also consider other less obvious factors which could influence pilot behaviour. E.g. how is upset recovery training taught, has the industry over promoted quick reactions to make a nose-down control input, what scenarios are trained in the simulator.
These 'minor', apparently inconsequential contributions could be disregarded, but in extreme circumstance they may be a significant, although not an immediate apparent aspect. The industry has to be aware of 'Meldrew moments' * "I don't believe it'.
This is similar to citing human error as a cause, which should trigger the need to look deeper in the accident; thus any potential contribution judged "I don't believe it ...' should be reconsidered, look deeper for underlying assumptions associated with a less obvious contribution.
* 'Meldrew moments' (MM) from a British tv comedy involving the catchphrase "I don't believe it'.
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@ Uplinker
The first of those already exists, and was even started at the operator (1.18.3 in the report details this - the requirement was going to be effective in May, the accident happened in January; the operator had started to train their crews in anticipation, but these guys hadn't had that training yet). Would it have made a difference - who knows?
In the light of recent accidents, I think that two other mandatory elements should be added to every SIM from now on:
1. Unusual attitude recovery.
2. Primary instrument failure, identification and recovery.
1. Unusual attitude recovery.
2. Primary instrument failure, identification and recovery.
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. Would it have made a difference - who knows?
If you see something in the box one day, then see it on the line the day after, you already "know what to do".