AF447 - French prosecutors sends AF to court for negligence

[RobertP]

I too read the BEA report when it was finally issued and have struggled with the same questions as yourself. It has taken far too long to get even to this stage. I hope the prosecution goes ahead.

[Astir 511]

Originally Posted by Peter H

I quoted somebodies timeline on this in A380 engine piece found in Groenland after 9 months

Thanks for the reference, I think the point I was trying to make (albeit not very successfully, my bad!) is that in terms of Timeline to adopt the Mod, if the Regulators had deemed the probe reliability as a flight safety risk they would have issued an AD, and the Timeline for terminating action on the AD would have been driven by the Regulator's Risk Assessment. There wasn't an AD, therefore it's difficult to criticise AFI for a "perceived" slow adoption. At my Airline we embodied the Mod aggressively, as our own Safety Assessment deemed it prudent. But it was a judgement call, as was allowed by the absence of an AD.

[RobertP]

Originally Posted by Lord Bracken

As ever, it is worth rewatching the official BEA animation of what the pilots were presented with on their PFDs.


It should have been abundantly clear to everyone the aircraft was stalled at a high AOA.

A permanent record of terrifying incompetence! It still scares me years later.

[Timmy Tomkins]

I thought there had been a notice ussued by Airbus 3 years before this and AF had elected not to replace the Pitots? Had they done so - competence aside; and it is a shocking video - there may not have been an accident to discuss.

[aixois]

ood evening,

There was also (sorry if it had been already uploaded some months or years ago here) an Airbus notice on "Unreliable Speed" published 2 years before the loss of AF 447 flight.

http://www.airbus.com/content/dam/co...agazine_05.pdf

See page 14 till 19 of the document.

Sincerely

[ATC Watcher]

The text of the prosecution has been published ;

[AF provided] insufficient information to its crews about incidents (of the PITOT probes) that occurred during the previous months, their consequences and the procedure to be applied, in a context of insufficient pilot training at high altitude, of a lack of adaptation of their training, and operational failure ",

The SNPL issued a statement earlier today attacking Airbus . Unfortunately only in French here : https://snpl.com/cp-requisitoire-inc...nsible-airbus/

[blind pew]

About time

That someone was prosecuted for incompetence rather than the cover ups and protecting the establishment that has existed in aviation since the Munich Disaster. Hope it succeeds as it can only enhance safety and politics but....

[tdracer]

Originally Posted by Old Dogs

Not sure how you train a guy not to hold the stick in the full aft position from 36,000 to sea level. 😏

I don't want to turn this into another Airbus/Boeing bash fest, but I suspect there is some cause/effect due to the pronouncements from Airbus (and others) that 'it's impossible to stall this aircraft'.
In an emergency, the human mind may not remember whatever qualifications may have been put on that statement - e.g. 'in the full up control mode'. He just remembers 'impossible to stall'.
With that in mind, if his brain was telling him it's 'impossible to stall', holding the stick full back while the aircraft drops like a rock (even with the "stall stall" warnings) is somewhat easier to understand.

Tell the pilot that there are anti-stall protections to 'help', but don't tell them they can't stall it because in the right circumstances, they can stall it.

[ph-sbe]

Originally Posted by RobertP

A permanent record of terrifying incompetence! It still scares me years later.

Exactly this. This is bone-chilling to watch. Such a gross incompetence.

That said, I believe it is unfair to prosecute the airline. While the airline has some responsibility to ensure a certain level of training, it is not responsible for an airmen's basic competence. That is the responsibility of the certificating authority, in this case (I assume) the French government themselves. They issued the airman's certificate and appropriate ratings. They are responsible for the airman's checkrides and recurring bi-annuals.

A taxi company is not responsible for a driver's ability to drive; once the driver presents a valid, government issued driver's license in the appropriate class, the company should be able to safely assume that the driver has had the proper training and driver's test. The same is true here.

[UltraFan]

Originally Posted by Old Dogs

1) Level the wings - more or less.
2) Put the pitch bar on the horizon - more or less.
3) Put the throttles in the middle - more or less.
4) Stop and think.

May I suggest (regardless of anyone present) that this course of thinking was exactly what brought that plane down. I have to do something! Thought the pilot. WHY!? Wasn't on his mind. The wings were level and the plane was flying straight. The attitude was exactly fine. The engines were spinning and served them perfectly well. They reduced speed to react to turbulence. The only thing worth stopping and thinking about in that particular situation was what to order from the galley.

Honestly, I can't think of another major accident, let alone a crash, that resulted from a situation where, to save the plane, pilots had to do exactly nothing. They were busy doing nothing before the incident, they had to remain doing nothing during the incident, and after the incident, they should've continued diligently doing nothing.

[UltraFan]

Originally Posted by Lord Bracken

As ever, it is worth rewatching the official BEA animation of what the pilots were presented with on their PFDs.

It should have been abundantly clear to everyone the aircraft was stalled at a high AOA.

Thank you for this. I couldn't find it. I'm not looking at the PFDs, I'm looking at the timer in the upper center of the screen.

02:10:05 Autopilot disconnects. Speed indication unreliable.
02:10:35 Twenty seconds later Pitot 1 deiced.
02:10:46 Thirty seconds later Pitot 2 deiced.
02:11:07 One minute later Pitot 3 deiced, and the plane was back to normal.

However,
02:10:06 ONE second after AP/AT disconnect, and look at the right sidestick and throttles.

Unbelievable.

[phylosocopter]

Originally Posted by UltraFan

May I suggest (regardless of anyone present) that this course of thinking was exactly what brought that plane down. I have to do something! Thought the pilot. WHY!? Wasn't on his mind. The wings were level and the plane was flying straight. The attitude was exactly fine. The engines were spinning and served them perfectly well. They reduced speed to react to turbulence. The only thing worth stopping and thinking about in that particular situation was what to order from the galley.

Honestly, I can't think of another major accident, let alone a crash, that resulted from a situation where, to save the plane, pilots had to do exactly nothing. They were busy doing nothing before the incident, they had to remain doing nothing during the incident, and after the incident, they should've continued diligently doing nothing.

ahh as soon as to AP disconnects, the craft will start to roll! some intervention is required to keep wings level after AP disconnect.

my question is , were they at that point (immediately after AP disconnect) seeing a raw gyro attitude display or were they seeing some flight director telling them to go up?

My view is that BOTH the manufacturer and the regulator should be facing questions here because the state of alarms and displays at time of unreliable airspeed is not defined in regulation (as far as I can see)

edit.... have now found this discussion of the accident report that answers some of my question at
https://www.ainonline.com/aviation-n...pitch-commands"A major new finding in the final report concerned the flight director, which normally displays symbology on the pilots’ primary flying displays that give guidance on control inputs to reach a desired steady-state flightpath. After the autopilot and autothrottle disengaged, as the flight control law switched from normal to alternate, the flight director’s crossbars disappeared. But they then reappeared several times. Every time they were visible, they prompted pitch-up inputs by the PF, investigators determined. It took them a long time to “rebuild” what the flight director displayed since this is not part of the data recorded by the flight data recorder.The BEA acknowledged that the PF might have followed flight director indications. This was not the right thing to do in a stall but it seems that the crew never realized that the aircraft was in a stall. Moreover, the successive disappearance and reappearance of the crossbars reinforced this false impression, the investigators suggested. For the crew, this could have suggested their information was valid.None of the pilots recognized that the flight director was changing from one mode to another because they were just too busy. The PF may have trusted the flight director so much that he was verbally agreeing to the other pilot’s pitch-down instructions, while still actually pitching up.The BEA’s report includes significant recommendations about the flight director. One of them calls for European Aviation Safety Agency to review its “display logic.” The flight director should disappear or present “appropriate orders” in a stall."
from

[Old Dogs]

Originally Posted by UltraFan

May I suggest (regardless of anyone present) that this course of thinking was exactly what brought that plane down. ... The wings were level and the plane was flying straight. The attitude was exactly fine. The engines were spinning and served them perfectly well.

Then they have already accomplished Steps 1 through 3, right?

[Uplinker]

I had not seen this video before, but it is immediately obvious that the RHS pilot has not been taught how to correctly use the Airbus FBW side-stick and it is clear that he also did not know or did not remember the correct memory drills for unreliable speed or a stall.

I don’t know what he is looking at but he does not appear to notice the pitch or the IVSI. As soon as ‘Stall Stall’ is first heard, he does not dip the nose (pitch down), as you should in a stall not at lift-off, and a few ‘stall stall’s later he goes to TOGA. I wonder if he is doing Stall at lift-off drill (TOGA and pitch +15°)? He spends most of the time after that holding the side-stick aft of neutral and fussing about keeping wings level, (not a priority for nose high upset), as well as over controlling and almost never pushing forward.

This illustrates lack of sufficient handling training and lack of sufficient memory drill practise. Memory drills need to be instinctive - almost reflex actions. This can only be developed if pilots have sufficient physical practise. You don’t need a six axis FFS SIM to practise memory drills, but you do need some sort of instrument simulator with the same displays, controls and control feel as the real thing.

[infrequentflyer789]

Originally Posted by ph-sbe

A taxi company is not responsible for a driver's ability to drive; once the driver presents a valid, government issued driver's license in the appropriate class, the company should be able to safely assume that the driver has had the proper training and driver's test. The same is true here.

Not quite, IMO. A taxi company would not usually be responsible, however:
IF the taxi manufacturer notified the operator that they were getting a far higher than expected rate of taxi speedo failures for taxis with speedo model A in bad weather at motorway speeds, speedo failure affects the power steering which makes the vehicle a bit skittish and might cause a crash if the driver isn't up to it, and the manufacturer recommends replacing model A speedo with model B which is designed perform better...
THEN liability might fall on the taxi operator depending on how they responded to that notice

That appears to be what is happening in this case, and is also why this is very different to 737 MAX (despite what SNPL says) - this is not about general pilot competency or training it is about response to the specific risk identified prior to the event and notified by Airbus (in contrast, it appears that if Boeing did identify a risk it chose not to inform operators or pilots).

The taxi operator might, hypothetically, do some or all of the following:

(1) Tells taxi mfr to get stuffed on replacing speedos unless it builds a new adverse weather test rig and proves that model Bs are better than model As (note that model C from another parts mfr is already known to be better)
(2) Does a proper assessment of the increased risk and concludes there is no cause for concern and it's drivers will be able to handle the problem (not the same as assuming they will because they have the correct licence, since the licence training was designed for risk levels which have just been advised to be incorrect)
(3) Issues a warning to their drivers notifying the risk and specifying the correct handling procedures
(4) Checks their drivers' proficiency in handling this situation by testing a random sample in recurrent training/checks, and finds no problems
(5) Ensures all their drivers are tested on this scenario in recurrent training/checks

The question is what would be a negligent response, falling below the standard expected of a reasonable operator. My vaguely educated guess is that any combination involving (4) or (5) would be a solid defence, anything involving (2) or (3) would be less solid defence, actually doing nothing might be ok, but doing (1) and only (1) would have your lawyer shaking their head - because I think (1) may be seen as accepting liability for the notified risk, and "only (1)" means then doing nothing to mitigate it...

Based on many reports I have read, AF actually did (1), question then becomes what else did they do. If the answer is nothing, then I think they have a problem, and I have thought that for several years now - none of this is surprising me, the wheels of French justice turn very slowly, but that isn't surprising either.

[RickNRoll]

Originally Posted by phylosocopter

ahh as soon as to AP disconnects, the craft will start to roll! some intervention is required to keep wings level after AP disconnect.

my question is , were they at that point (immediately after AP disconnect) seeing a raw gyro attitude display or were they seeing some flight director telling them to go up?

My view is that BOTH the manufacturer and the regulator should be facing questions here because the state of alarms and displays at time of unreliable airspeed is not defined in regulation (as far as I can see)

edit.... have now found this discussion of the accident report that answers some of my question at
https://www.ainonline.com/aviation-n...pitch-commands"A major new finding in the final report concerned the flight director, which normally displays symbology on the pilots’ primary flying displays that give guidance on control inputs to reach a desired steady-state flightpath. After the autopilot and autothrottle disengaged, as the flight control law switched from normal to alternate, the flight director’s crossbars disappeared. But they then reappeared several times. Every time they were visible, they prompted pitch-up inputs by the PF, investigators determined. It took them a long time to “rebuild” what the flight director displayed since this is not part of the data recorded by the flight data recorder.The BEA acknowledged that the PF might have followed flight director indications. This was not the right thing to do in a stall but it seems that the crew never realized that the aircraft was in a stall. Moreover, the successive disappearance and reappearance of the crossbars reinforced this false impression, the investigators suggested. For the crew, this could have suggested their information was valid.None of the pilots recognized that the flight director was changing from one mode to another because they were just too busy. The PF may have trusted the flight director so much that he was verbally agreeing to the other pilot’s pitch-down instructions, while still actually pitching up.The BEA’s report includes significant recommendations about the flight director. One of them calls for European Aviation Safety Agency to review its “display logic.” The flight director should disappear or present “appropriate orders” in a stall."
from

IIRC, one of the UAS procedures is to turn off the FD.

As an aside, the auto-pilot could probably be programmed these days to cope with a UAS event without disconnecting.

[sonicbum]

Originally Posted by tdracer

I don't want to turn this into another Airbus/Boeing bash fest, but I suspect there is some cause/effect due to the pronouncements from Airbus (and others) that 'it's impossible to stall this aircraft'.
In an emergency, the human mind may not remember whatever qualifications may have been put on that statement - e.g. 'in the full up control mode'. He just remembers 'impossible to stall'.
With that in mind, if his brain was telling him it's 'impossible to stall', holding the stick full back while the aircraft drops like a rock (even with the "stall stall" warnings) is somewhat easier to understand.

Tell the pilot that there are anti-stall protections to 'help', but don't tell them they can't stall it because in the right circumstances, they can stall it.

Airbus never stated that any FBW aircraft is impossible to stall. They have always emphasised the fact that flight control protections are there to prevent entering a stall, i.e. exceeding the stalling AOA. If those protections are not available due to a flight control system downgrade, then it is obvious that the stall AOA can be reached and exceeded and this is exactly what thousands of pilots learn during their type rating and it has always been the same for the past 30 years. If a pilot's muscle memory connects "FBW = no stall" and nothing else, then there are issues that need to be tackled somewhere within the SHELL, which is basically what has happened in the past 10 years since the accident, by increasing crew exposure to high altitude hand flying in alternate law, stall recovery and unreliable speed management. Airbus sells You a product, tells You how it works in detail (that is not always the case in the industry apparently) and gives you support to build training programs. They do not have a crystal ball and foresee how each and every airline pilot will react to any system anomaly, as this is part of the operator's duties to ensure proper guidance is given and maintained trough a proper system of recurrent training and checking.

[Sunamer]

Originally Posted by KingAir1978

I sincerely hope that this gets thrown out.

Imagine the precedent if this would result in a conviction? It is simply impossible to train crew for every conceivable scenario... Would be very interesting indeed to see the full text and the eventual outcome.

yes, it is absolutely impossible to train a flight crew on how to avoid a high altitude stall...
No one has ever done that before and the science still does not know how it occurs. /s

How about, for starters, training pilots that pulling the sidestick all the way aft for prolonged periods of times might not be a good idea, especially when AXXX plane is in a degraded law mode, which lacks protections? How about teaching pilots to do something similar to what AA Advanced aircraft maneuvering course was designed to teach? How about...ah, forget it!

AF447 was a disgrace..and it was a case nowhere near the complexity of some kind of fringe case and a very rare event, which it was not.

[Sunamer]

Airbus shot themselves in the foot with their "get our planes, train your pilots less = big $$$ savings" sales pitch.
They created a false sense of security by adding a ton of automation. Of course, children of the magenta (green, in this case) will abuse that automation and erode their skills until the erosion is sufficient enough to cause a crash.

[FlightDetent]

Originally Posted by tdracer

I suspect there is some cause/effect due to the pronouncements from Airbus (and others) that 'it's impossible to stall this aircraft'.
In an emergency, the human mind may not remember whatever qualifications may have been put on that statement - e.g. 'in the full up control mode'. He just remembers 'impossible to stall'.
With that in mind, if his brain was telling him it's 'impossible to stall', holding the stick full back while the aircraft drops like a rock (even with the "stall stall" warnings) is somewhat easier to understand.

Tell the pilot that there are anti-stall protections to 'help', but don't tell them they can't stall it because, in the right circumstances, they can stall it.

The claim that "Airbus FBW are impossible to stall" is not something we say in the assimilated collective, td!

There is a demonstration of a ground escape technique with hard AoA hard protections (pull full back-stick, fear nothing). If that is left to be the strongest impression on the student, many things had gone severely sideways in the training. On the first day of the groundschool, the student gets a card with Golden Rules where number 1 is "This aircraft can be flown like any other aircraft". The reaction to a stall must be instinctive, immediate and decisive - this must be the lymphatic system of a pilot's body, FROM THE PRE-SOLO DAYS!

The fatal actions the AF447 pilot are quite the same as we saw in the Buffalo accident, impossible to make any sense of. Clearly, the Continental Connection Dash8 Q400 crew was not infested with any of what's suggested, and we saw the reaction of the World's best overall aviation system (I mean that honestly in awe) - mandate 1500 hrs.
That's a strange compromise. A sad optimum of available solutions, many of our shared community shake heads in disbelief. But it is looking in the right direction - pilot basic skills - even if amalgamating flight hours, experience, and skills into one bucket not too smartly.

In real life, there must be a scope to a pilot type conversion curriculum, any brand or model. Specific features are shown and trained, characteristic behaviour for the class explained. During the exam apart from the type-specific knowledge and skills, the student will as well need to demonstrate the elementary items (stalls, turns, respecting weather minima, deicing the airfoils, DDG compliance) However, those do not come from the training objectives of the aeroplane type rating course itself.

That being said, lives got lost and there shall be no stone left unturned until it is certain that our understanding of what and why it happed is complete. A prosecution may find some more, that is not a bad thing by default. Some ideas of mine, being a fan of technology and Airbus FBW concept (as non-perfect as the aircraft may be, similar to any other) to entertain:

It is my personal hunch is AF447 could have flown into the weather unknowingly. Or some other will (and did since)
- there is a worldwide obsession of pilots to keep the radar OFF. Completely unsubstantiated. Forgetting to switch it on when entering a night segment or IMC happens waaaay too often.
- the Airbus design of the intensity knob for WXR overlay is conducive to turning the ND brightness and radar display to dim after a flight, but only the screen itself back on. Possibly leaving the crew facing a working ND with WXR on, but no radar image on it.

The controlling pilot kept pulling, contributing cues:
- speed so low at extremes of the nose-up pull, the STALL warning ceased due to IAS outside the defined range for the stall warning.
- flight directors re-appearing in a high-nose positon
-> You pull (wrongly) and the horn stops, you release (correctly) and it comes screaming again. You are back of the clock, scared witless, nothing you see resembles anything and all is impossible to interpret at the same time. Yet, now and then, the saviour FD bars flash high up in the ATT indicator. That is seriously bad human factors mojo.
- was there not a glider pilot among the crew, I heard so somewhere.

Ther other pilots present did not intervene enough.
- who had been certainly perplexed too, but perhaps not cognitively lost yet
- disconnected side-sticks, out of sight left side from the right and v.v.
(Similar case for Air Asia 5801. The last two links of the accident chain: x) disoriented F/O pulled into a pronounced unusual attitude z) the ex-F16 captain misunderstood the inputs and later failed to operate the sidestick effectively to recover).

Cockpit video recorders.
- 19 years overdue, seriously.

----------------
Some of the points I raise above have been targeted and are being dealt with. The WXR and side-stick take over not sufficiently in my opinion.

sonicbum: waistline! Otherwise, we cannot claim to be better