Air France and Airbus to stand trial 2009 crash
A challenge for the industry is an increasingly litigious society, where people seek retribution with little consideration of the much higher standard of safety. This could restrain learning from events required to improve, or at least to maintain existing standards.
An emerging risk of inaction could reduce the perceived level of safety, continuing a vicious circle of more procedures, rules and litigation.
The baseline for the legal action was an accident resulting from simultaneous multiple sensor malfunctions where the acceptable probability of occurrence was beyond the certification requirements. It might be argued that the in-flight risk pending modifications identified from previous malfunctions could have been better judged; which would rely on on human (crew) understanding in real time.
The regulator has responsibilities for both design requirements and airworthiness issues, thus with increasing complexity in systems and operations the regulator should also be involved in the legal process - but to what point. Ever increasing systems integrity to counter extremely rare, and often unforeseeable circumstances which involve indeterminate human response - another vicious circle in the quest for perfect safety.
An emerging risk of inaction could reduce the perceived level of safety, continuing a vicious circle of more procedures, rules and litigation.
The baseline for the legal action was an accident resulting from simultaneous multiple sensor malfunctions where the acceptable probability of occurrence was beyond the certification requirements. It might be argued that the in-flight risk pending modifications identified from previous malfunctions could have been better judged; which would rely on on human (crew) understanding in real time.
The regulator has responsibilities for both design requirements and airworthiness issues, thus with increasing complexity in systems and operations the regulator should also be involved in the legal process - but to what point. Ever increasing systems integrity to counter extremely rare, and often unforeseeable circumstances which involve indeterminate human response - another vicious circle in the quest for perfect safety.
It's perhaps unfair to label as vengeful those who take legal action against parties they believe responsible for killing their family members. Retribution in the eyes of some may be just, if inadequate, compensation in the eyes of others. But the issue isn't about a point of perspective. I fully understand that learning from errors requires transparency which may be at odds with the adversarial nature of litigation. That tension isn't new and will never be resolved. But there is also a corner where the failures of supposedly highly-trained and trusted professionals reach the level of negligence, even criminal negligence. And to justify allowing culpable individuals to escape responsibility on the alter of fixing safety flaws in the system seems unjust.
So, to follow you, in fact, it should not be Air France or Airbus going to court but the certification authorities because they did not define strong certification requirements..
voyageur, agreed; it would be unfair to ‘label’ people, but that was not the intention. The point was to highlight that the apparent change - seeking more compensation etc, could have greater effect on the industry than we appreciate.
With increasing safety the industry moves way from blame, more towards understanding and thence learning. If there is no corresponding adjustment of legal view then the widening gap may create greater opportunity for compensation. With different viewpoints, the public might be less appreciative of the concept of error and blame as is aviation; thus legal findings could tend towards public perception. Also, whilst operations are conducted in complex multitasking situations where there are many demands on thinking and understanding, the legal process with hindsight, might only consider each of the demands sequentially, without the context of a demanding situation.
The legal process might not fully understand the tasks the crews face during an event, or designers and operators inability to foresee every alternative human reaction in surprising situations; thus culpability might only be concluded with hindsight.
With increasing safety the industry moves way from blame, more towards understanding and thence learning. If there is no corresponding adjustment of legal view then the widening gap may create greater opportunity for compensation. With different viewpoints, the public might be less appreciative of the concept of error and blame as is aviation; thus legal findings could tend towards public perception. Also, whilst operations are conducted in complex multitasking situations where there are many demands on thinking and understanding, the legal process with hindsight, might only consider each of the demands sequentially, without the context of a demanding situation.
The legal process might not fully understand the tasks the crews face during an event, or designers and operators inability to foresee every alternative human reaction in surprising situations; thus culpability might only be concluded with hindsight.
Bidule, we should not blame certification authorities for a judgement of risk which has been accepted world wide and shown to be be adequate for many systems - and in other industries.
A rule change at this level would probably generate more automation vice attempting to quantifying the variable human in a risk assessment.
The critical point in this safety event is that it happened at all - obviously. There was a component malfunction - three simultaneously, which by all available means had been shown to be adequate. Meeting the requirements at the time, requirements which via higher accountability were acceptable to government and thence the public.
If change is warranted, then consider the process; which apparently has been improved in the icing requirements in CS 25; greater emphasis on ice crystals.
Also, in addition to the mandated modified probe, the manufacture has improved ADC logic, switching, and crew interface, yet some views cite this as an admission of prior error. Operators have reviewed checklists and training, but these and modification are obvious fallacies if used to justify uneducated criticism, which could generate a reluctance to improve safety - ‘we meet the regulation’ - ok, no more.
The industry requires a learning culture to progress safety, a willingness to advance beyond the minimum standard; the question is if increasing litigious action will hinder developing a safety culture - not change rules.
The Certification Authorities should appear for the defence.
A rule change at this level would probably generate more automation vice attempting to quantifying the variable human in a risk assessment.
The critical point in this safety event is that it happened at all - obviously. There was a component malfunction - three simultaneously, which by all available means had been shown to be adequate. Meeting the requirements at the time, requirements which via higher accountability were acceptable to government and thence the public.
If change is warranted, then consider the process; which apparently has been improved in the icing requirements in CS 25; greater emphasis on ice crystals.
Also, in addition to the mandated modified probe, the manufacture has improved ADC logic, switching, and crew interface, yet some views cite this as an admission of prior error. Operators have reviewed checklists and training, but these and modification are obvious fallacies if used to justify uneducated criticism, which could generate a reluctance to improve safety - ‘we meet the regulation’ - ok, no more.
The industry requires a learning culture to progress safety, a willingness to advance beyond the minimum standard; the question is if increasing litigious action will hinder developing a safety culture - not change rules.
The Certification Authorities should appear for the defence.
safetypee. You are absolutely correct that the legal process to assign blame and/or impose punishment or set compensation is backwards-looking. Juries (or judges) reach binary verdicts (guilty or not guilty) or assign shares of culpability and hence compensatory and/or punitive damages in a process that requires judgement in hindsight. It's also true that it may be easier to conclude negligence when a babysitter allows an infant to drown in a bathtub because he/she didn't notice the plug was in than when three supposedly skilled, highly-trained, and expensively compensated professional pilots fail to recognize a stall for several minutes in perfectly flyable aircraft thus causing the deaths of several hundred people. I was only pressing the point that culpability in the cockpit (or the training school, or even the regulatory agencies) shouldn't be set aside because it might make lesson-learning more difficult. best regards.
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safetypee
It would be enlightening, and at the least quite interesting, to find out what KSAs you hold with regard to civil litigation involving air crashes or accidents (knowledge, skills, and abilities - a standard assessment metric in American higher education including legal education).
i say this not because I disagree with any particuar assertion you've articulated about legal processes in general or about ""the" legal process. Rather, as a result of having had a fairly broad set of professional interactions with accomplished litigators - some in the defense bar, others for plaintiffs - over several years now, it's unclear to me which interrogative is the more pertinent one: Other than abstruse pronouncements about how safety-related processes function, what basis in actual fact or experience do you assert supports your view about litigation in these cases? (Aren't your posts generally long on abstractions, tending toward theoretical?) Or..... let's say you're actually one of the above-referenced top-drawer American courtroom litigators of renown, posting behind an assumed identity.....So, what foundational changes are you advocating in the Montreal system which (as is widely known and recognized) is the bedrock of civil litigation for international civil aviation?
[Any perceived snark or sarcasm in this post is both apologized for in advance, and not intentional.]
It would be enlightening, and at the least quite interesting, to find out what KSAs you hold with regard to civil litigation involving air crashes or accidents (knowledge, skills, and abilities - a standard assessment metric in American higher education including legal education).
i say this not because I disagree with any particuar assertion you've articulated about legal processes in general or about ""the" legal process. Rather, as a result of having had a fairly broad set of professional interactions with accomplished litigators - some in the defense bar, others for plaintiffs - over several years now, it's unclear to me which interrogative is the more pertinent one: Other than abstruse pronouncements about how safety-related processes function, what basis in actual fact or experience do you assert supports your view about litigation in these cases? (Aren't your posts generally long on abstractions, tending toward theoretical?) Or..... let's say you're actually one of the above-referenced top-drawer American courtroom litigators of renown, posting behind an assumed identity.....So, what foundational changes are you advocating in the Montreal system which (as is widely known and recognized) is the bedrock of civil litigation for international civil aviation?
[Any perceived snark or sarcasm in this post is both apologized for in advance, and not intentional.]
Hi Willow, no legal expertise as in your sphere; at best a layman (see pm).
However, sufficient experience in aviation, flying, testing and certification, and incident investigation - supporting formal investigations - to participate an abstract discussion from the aviation viewpoint.
My simple view of the legal position is that AF & Airbus are appealing the investigation finding, and subsequent court rulings and appeals which allow a prosecution to proceed - post #2, et al.
How can a manufacturer be held responsible for an aircraft which met all requirements, yet suffered a failure at a level of probability not considered by certification.
How might any differences between world aviation standards and local legal findings to be judged.
Similarly, how can an operator be held responsible for a situation (triple ADC malfunction and consequential system alerts) for which specific training was not required, and that training which was required had been approved by the regulator.
An adverse outcome, Manufacturer and/or Operator being held accountable for a situation, which previously met requirements of certification and training, would have detrimental effect for aviation and safety in general.
However, sufficient experience in aviation, flying, testing and certification, and incident investigation - supporting formal investigations - to participate an abstract discussion from the aviation viewpoint.
My simple view of the legal position is that AF & Airbus are appealing the investigation finding, and subsequent court rulings and appeals which allow a prosecution to proceed - post #2, et al.
How can a manufacturer be held responsible for an aircraft which met all requirements, yet suffered a failure at a level of probability not considered by certification.
How might any differences between world aviation standards and local legal findings to be judged.
Similarly, how can an operator be held responsible for a situation (triple ADC malfunction and consequential system alerts) for which specific training was not required, and that training which was required had been approved by the regulator.
An adverse outcome, Manufacturer and/or Operator being held accountable for a situation, which previously met requirements of certification and training, would have detrimental effect for aviation and safety in general.
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safetypee
Having pilots who do not understand or recognise a stall, or who do not know what action to take to recover from a stall it rather startling. It is one of the fundamental aspects of flying a fixed-wing aeroplane.
Having pilots who do not understand or recognise a stall, or who do not know what action to take to recover from a stall it rather startling. It is one of the fundamental aspects of flying a fixed-wing aeroplane.
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grizzled
these are good points and as in any accident, ‘everything’ should be considered relevant, unless proven otherwise i.e. rule out factors one by one and not have to rule them in
these are good points and as in any accident, ‘everything’ should be considered relevant, unless proven otherwise i.e. rule out factors one by one and not have to rule them in
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The probable answer to that question "why did nobody, ( 3 of them) recognize the stall " is described in the the 1984 Charles Perrow book , " Normal accidents " describing among other things the 3 Miles Island nuclear accident.
There is a difference in Human factors between what is logical on paper, and how humans faced with unknowns and stress react. Training is supposed to help bridging that gap. Training for stall recovery in one thing, but recognizing a stall starting with wrong indications on displays is another.
There is a difference in Human factors between what is logical on paper, and how humans faced with unknowns and stress react. Training is supposed to help bridging that gap. Training for stall recovery in one thing, but recognizing a stall starting with wrong indications on displays is another.
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And consider also the condition at the moment , was not a stall recovery in still air by day , they where by night , in the middle of ITCZ , cb all around maybe inside , so probably extreme shear and turbulence , lightning , add the startle effect , not an easy job even will full data working .
Noel, et al, we have to consider what assumptions are in the questions; our inability to understand crews’ behaviour at the time, without benefit of hindsight.
Pilots are trained for stall recognition and recovery; they are not trained for the combination of erroneous airspeed and stall - manual flight at high altitude with many systems alerts and distractions. Nor in turbulence which masks natural stall warning, or stall at night / IMC, or with revised control laws, or …, … or in the real aircraft in a rare, surprising, complex situation.
The article below is an overview of the investigation and HF issues relevant to the questions.
Also see page 6 which relates to legal aspects (this thread), particularly the French view:-
“This investigation does not seek to determine responsibilities—that is the role of the judicial investigation that takes place in parallel and independently of ours, as laid out in French law. Unfortunately, in the mind of the public, it is not always easy to understand the difference. Many people expected the BEA investigation to point out responsibilities and even culpabilities.”
https://skybrary.aero/bookshelf/books/3337.pdf
Accident Investigation page 6 - ; and Human Factors Issues page 9 -.
Pilots are trained for stall recognition and recovery; they are not trained for the combination of erroneous airspeed and stall - manual flight at high altitude with many systems alerts and distractions. Nor in turbulence which masks natural stall warning, or stall at night / IMC, or with revised control laws, or …, … or in the real aircraft in a rare, surprising, complex situation.
The article below is an overview of the investigation and HF issues relevant to the questions.
Also see page 6 which relates to legal aspects (this thread), particularly the French view:-
“This investigation does not seek to determine responsibilities—that is the role of the judicial investigation that takes place in parallel and independently of ours, as laid out in French law. Unfortunately, in the mind of the public, it is not always easy to understand the difference. Many people expected the BEA investigation to point out responsibilities and even culpabilities.”
https://skybrary.aero/bookshelf/books/3337.pdf
Accident Investigation page 6 - ; and Human Factors Issues page 9 -.
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"why did nobody, ( 3 of them) recognize the stall "
For everyone who has an interest in the causes and contributory factors for this accident, the following article, written for Vanity Fair by William Langewiesche in 2014, is as good a summary as you will find. The interrelationships that came together that night (automation, training, human factors, culture, CRM, etc.) are all discussed – and explained well enough for a general audience to comprehend.
https://www.vanityfair.com/news/busi...ight-447-crash
There is much more to this accident than "the pitot tubes became blocked with ice", or "there was no adequate procedure at the time", or "lack of training in high altitude stall", or "awareness and implications of Alternate Law".
https://www.vanityfair.com/news/busi...ight-447-crash
There is much more to this accident than "the pitot tubes became blocked with ice", or "there was no adequate procedure at the time", or "lack of training in high altitude stall", or "awareness and implications of Alternate Law".
Last edited by grizzled; 26th May 2021 at 20:47.
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But were they actually trained at all in a relevant scenario (whether sim was faithful or not) ? I understood from the report that they were definitely not trained in either stall or UAS at cruise alt, only at low level where handling and required responses are different. Were they ever trained in alternate law at cruise altitude, at all ? - the report mentions alt law training but also states it was at low level, in fact high altitude alternate law training is stated as a change made following the accident (which pretty much implies it wasn't done before). If they were never trained, the simulator fidelity, or lack of, is kind of irrelevant.
But were they actually trained at all in a relevant scenario (whether sim was faithful or not) ? I understood from the report that they were definitely not trained in either stall or UAS at cruise alt, only at low level where handling and required responses are different. Were they ever trained in alternate law at cruise altitude, at all ? - the report mentions alt law training but also states it was at low level, in fact high altitude alternate law training is stated as a change made following the accident (which pretty much implies it wasn't done before). If they were never trained, the simulator fidelity, or lack of, is kind of irrelevant.
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Quite right, hence my word may. One of my annoyances is that at the time our training aides did not represent the real aircraft. It will be interesting to see if this comes up in the court case. I also wonder in reality how many pilots have actually “hand” flown any FBW Airbus at high altitude. Certainly a skill you need when everything goes “pear shaped”.
