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-   -   AF 447 report out (https://www.pprune.org/rumours-news/489790-af-447-report-out.html)

Lonewolf_50 22nd May 2013 21:06


Originally Posted by Beagle
You cannot afford 'a bad day at the office' when you're flying an airliner.

Indeed, which is why crew rest, CRM, qualification, standards, training, etcetera, programs in the industry are in place.

This takes us back to root cause issues, which is how AF put into that cockpit a crew not able to avoid the bad day at the office.

Pilots are not stamped out of a sheet of aluminum, nor forged from identical base material. The entire science of human factors and crew training is based on mitigating for the fact that you don't have identical input when you are trying to make an airline pilot, and ultimately, an airline captain.

Yes, the crew flew a flyable plane into the ocean. If you stop there, nothing learned, nothing done to prevent the next one.

What I learned in my time doing mishap investigations is that one must, when human error is involved, dig into how many holes are in the cheese, and what drilled those holes.

One of the previous posters noted (yet again) that a procedure in the book was not used for UAS. How did Air France arrive at the place that when a UAS event occurred, its crew did not properly respond?

I realize that point has been raised time and again as the hamster wheel has spun on this topic. Organizational cultural factors are worth looking into. If part of our aim in this conversation is furthering accident prevention by learning something from a fatal accident, then addressing the human factors chain as far down into the weeds as can be is imperative.

Yet again, I apologize for the rodent abuse. :uhoh:

SlingsbyT67M200 22nd May 2013 21:21


They don't deserve respect. They didn't follow AF procedures. They caused the stall they didn't know they were in.

They dropped a perfectly flyable plane into the Atlantic.
Mistakes where made but I refuse to believe that we can blame (individual) the crew. Perhaps they where rusty or never learned how to deal in such a situation. Can’t give an answer to that. Meanwhile I rather prefer the wise words of Mr. Troadec then pointing an offender.


"If the BEA thought that this accident was only down to the crew, we would not have made recommendations about the systems, the training... which means that this accident could no doubt have happened to other crews," Mr Troadec added.

RobertS975 22nd May 2013 21:33

Lonewolf 50 has hit the nail firmly on the head in his last post. Obviously, the crew "screwed the pooch" (Urban Dictionary: screw the pooch) as a perfectly flyable airliner ended up pancaking into the Atlantic Ocean. But as he points out, the industry needs to comprehend what factors led a trained crew to make the errors that were indeed made. There are many factors involved and we have been hashing through them for a couple of years... disagreement in the pitot/static system leading to shutoff of automated systems. a stall warning system that turns off below a certain IAS, sidesticks instead of conventional control columns which may have provided better visual cues as to back pressure control inputs being made and so forth.

Training factors, crew rest factors, weather factors... really another example of the "holes in the cheese" lining up just so.

ExSp33db1rd 22nd May 2013 21:55


You cannot afford 'a bad day at the office' when you're flying an airliner.
But they occur.

The trick, as Lonewolf has said, is how best to deal with them.

bubbers44 22nd May 2013 23:05

You can't have a bad day at the office when you take the responsibility of flying hundreds of people through the sky, you have to make sure all of them are good and you know how to safely handle your aircraft. Simple stall recovery procedures were learned in the first five hours in all aircraft. Why do so many of you excuse this poor airmanship as ok?

Cool Guys 22nd May 2013 23:38


really another example of the "holes in the cheese" lining up just so.
I agree entirely. It is imposible to make things perfect but implementing improvments to all these factors (pitot tubes, stall warning, CRM, training, improved controls etc) will lead to a greatly reduced posibility of this type of tragic situation occuring again. Focusing on one issue and trying to make that perfect but leaving all other issues unchanged is likely to be less effective.

mm43 22nd May 2013 23:41


Simple stall recovery procedures were learned in the first five hours in all aircraft. Why do so many of you excuse this poor airmanship as ok?
This crew didn't even understand that they were stalled. Why?

Looking closely at the Flight Control Laws and how best to clearly prompt the crew into performing the appropriate corrective actions, is something the industry can deal with. Exactly how you deal with the psychology involved in getting those messages through to a crew that isn't receptive, is another matter.

In the beginning ....

jcjeant 22nd May 2013 23:49


Simple stall recovery procedures were learned in the first five hours in all aircraft.
Do you think that if these three pilots were flying a Cessna 172 going in a stall .. they would complete their flight by a crash in the sea?

bubbers44 23rd May 2013 01:03

No they wouldn't and all aircraft fly the same, just at different speeds. If they lost their AS, they still had altimiters and attitude indicators available so why did they soar up 3,000 ft and do a full stall and keep the side stick all the way back if they were professional pilots? I know you want to protect these pilots but would you do that?

bubbers44 23rd May 2013 02:13

All pilots are required to recover from a stall and not how to get into one. It is in basic training so professional pilot don't need to know this? OK, my airspeed goes away in an Airbus and it is ok to pull full back on the side stick and soar 3,000 ft into a stall and keep full back side stick until you hit the Atlantic Ocean? WTF??

SlingsbyT67M200 23rd May 2013 09:32


You would simply move it forward and eliminate the problem.
Problem solved :ugh:
Hopefully the recommendation “training programmes” will be more extensive.


Consequently, the BEA recommends that:
€EASA ensure the integration, in type rating and recurrent training programmes, of exercises that take into account all of the reconfiguration laws. The objective sought is to make its recognition and understanding easier for crews especially when dealing with the level of protection available and the possible differences in handling characteristics, including at the limits of the flight envelope; [Recommendation FRAN-2012-039]
I would have thought that at this, of all times, we ought to take a step back and have a real think about good principles. If you are interested you can find a free copy E book UPRT apstraining.com

jcjeant 23rd May 2013 20:52


Do you think that if these three pilots were flying a Cessna 172 going in a stall .. they would complete their flight by a crash in the sea?
bubbers44

No they wouldn't and all aircraft fly the same, just at different speeds. If they lost their AS, they still had altimiters and attitude indicators available so why did they soar up 3,000 ft and do a full stall and keep the side stick all the way back if they were professional pilots? I know you want to protect these pilots but would you do that?
Well you confuse me :)
So Rober-Bonin-Dubois will going in a stall with a Cessna 172 and will recover it but they will not recover the A330 from stall
Or .. you write that "all aircraft fly the same just a different speed" (and I will add myself ..different cruise altitude)
So why all good in a Cessna .. and tragedy in a A330 ?

bubbers44 23rd May 2013 21:28

Let me explain this just one more time. All aircraft have a stall speed, Cessnas about 45 knots, Airliners about 110 knots. You have an attitude indicator to make sure you don't pull up into a stall so keep it about 2 degrees nose up max in both planes. Keep adequate power above cruise power and you will be fine. If you choose to pull full back you won't. Most competent pilots will understand this in their 5th hour. We all did.

CONF iture 23rd May 2013 21:31


Originally Posted by dozy
The aircraft was oriented such that the vertical airflow was fouling the pitot tubes - I suspect it would also have been sufficient to give false AoA readings.

Why would it be as all they do is following the airflow.

jcjeant 23rd May 2013 22:29

Hi,

@bubbers44
Before you had write (in answer to my question if in a Cessna 172 .. Bonin-Robert-Dubois will finish the flight in the sea in case of stall ) "no they wouldn't"
So my question "why they will recover from stall in a Cessna 172 and not in a A330 ? " stay valid and not answered
Or .. why in stall they will pull full back in a A330 and not when in a Cessna 172 ?
Or .. do you think that in a Cessna 172 .. or any other plane they had made the same this day .. as full pull back ?
The rest of your answer :

All aircraft have a stall speed, Cessnas about 45 knots, Airliners about 110 knots. You have an attitude indicator to make sure you don't pull up into a stall so keep it about 2 degrees nose up max in both planes. Keep adequate power above cruise power and you will be fine. If you choose to pull full back you won't. Most competent pilots will understand this in their 5th hour. We all did.
I understand perfectly :)

bubbers44 23rd May 2013 22:35

Of course if you are clean the stall speed is around 160 knots in an airliner.

bubbers44 23rd May 2013 22:44

All aircraft stall recovery is using forward controls so it is quite simple to recover in a Cessna or Airbus doing the same thing. Reduce angle of attack so you aren't stalled any more. Quite simple.

md80fanatic 24th May 2013 00:59

Not that it matters but ....
 
If I had an automobile that was designed to not exceed the national highway speed limit, regardless of accelerator position, I'd simply hold the accelerator pedal to the floor and trust the automation to handle the rest. I'd continue to do so, especially when passing a radar-equipped police cruiser that does not pursue me with a speeding ticket in hand. (I'd assume I was not speeding)

That's a rather silly example of how this non-pilot thinks this unfortunate accident progressed to disaster. IMO, the pilots that night assumed they were no longer stalled because they were without the usual stall notification (below 60 knots) so trusted the envelope protection to only apply the elevator deflection (in lieu of full back stick) that would keep them just below the stall AoA.

God, I hope that makes sense. I am finding this long thread to be educational in many ways, please continue. (Back to my hole)

bubbers44 24th May 2013 01:36

Unfortunately these two pilots allowed the plane to zoom 3,000 feet into a full stall then continued to hold full back stick until impact with the ocean. After over 3 minutes of holding full back nothing could save this flight. We need to hire smarter pilots that know how to fly.

Green Guard 24th May 2013 02:46

Unfortunately not the first time...very similar one here on MD82

West Caribbean Airways Flight 708 - Wikipedia, the free encyclopedia

thus reducing their maximum performance. With the anti-ice system on, the highest altitude at which the overloaded aircraft could fly - without stalling - was reduced to only 31,900 feet. The captain noticed the reduction in engine power, but he couldn't realize the source of the problem. Therefore, he started a rapid descent, as a precaution. At that time, the airspeed was already near stall speed and the autopilot had kept a nose-up attitude to maintain a constant height. When the airliner was pummeled by a sudden updraft, it finally entered a stall condition and the crew mishandled it. Although the CVR picked up the First officer correctly diagnosing the situation as a stall and attempting twice to communicate this to the captain, the captain was likely confused by the unusual behaviour of the engines, due to the anti-ice system and probably the air flow disruption caused by the updraft. The captain thought he was struggling with an engine flameout, which he told the first officer to communicate to the ground controller, and did not recognise the deep stall situation; he then mishandled the stall by maintaining nose-up attitude, which further decreased speed and deepened the stall until the plane eventually crashed.


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