Framer : Interesting. I am not expert on Airbus CRM, but in my world ( smaller A/C and ATC) we are taught and we teach not to follow instincts but rather procedures. Also that one person, and only one is controlling and giving orders , especially during an abnormal situation. But maybe AF SOPs are different.

In this case we do not have the CVR , so we do not know if the taking over by PNF was perceeded by words like : "I have it" or " You take over " .
But knowing how the BEA writes reports, if following the pilots interviews,they would have been convinced that this had been the case, they would have mentioned it in the report. They keep refering to PF/ Pilot monitoring.

A few points on the report indicate a rather assertive PNF: the taking over the PA address to pax after the falling handset ( but again we do not know , that might have been preceeded by an order from the Capt) , the manual A/P disconnection and and the subsequent side stick inputs.

But surprisingly , the speeds selection , the later disengagement of A/T and pushing the thottles to TOGA were performed by the PF, so it may looks as if 2 people were trying to solve a turbulence/overspeed indication problem separately.
Maybe this was coordinated, I was not there, we do not have a CVR, so all this is mere speculation of course.
But this sentence on the report : could indicate that the PNF actions were not coordinated with PF.

Trying to understand, not to point fingers.

AF management politic = don't try to understand and want not point fingers (see Colin report -audit)
The results of this politic are commented at large in those forums ....

As an interested observer of remarks here, could the following have any relevance to this incident?

Report: Two Skywest AT72 and Sunstate DH8D at Gladstone on May 16th and May 17th 2012, takeoff in night conditions without runway lights

Inattention/Change blindess/Expectation bias.....

Hi,

Another event (this one was fatal) is the Bluegrass Comair accident
Comair Flight 191 - Wikipedia, the free encyclopedia

Re: upset report; rather surprised nobody has thought fit to comment on their radar setting technique;-

Both on 320 nm scale? In the climb? In ITCZ territory?! I find the roughest rides when flying through those small green blobs that appear seemingly out of nowhere at close range (i.e "dry" clouds that don't reflect well on radar, but are nevertheless well on the way to fully developed CB's; a lot of unseen energy pushing them all the way up to 35,000 ft).

But on a lighter note, liked this comment,

Special Investigation: "Air France the free fall"
 

Unfortunately this AF A319 rejected TWY T/0 at Sofia and the loss of separation on 7 Sept 2012 between A319 F-FRXC and B735 OK-XGB on approach to Prague, when AF F-FRXC allegedly deviated from standard procedures after way point ERASU and reportedly ended up in the flightpath of the Czech Airlines B735 already established on finals, seem to fit in with the gist of a recent investigative French TV reportage on AF:


Having said that, on the LBSF incident, not necessarily to excuse the AF-crew or to say anything negative about LBSF (on the contrary, its a fine airport), but just to point out that AF normally is at parking positions 1-4 on the east-side of T2. With most of the time T/O being from RWY 27, AF would take TWY L and H to RWY 27. Or in the more rare case of T/O from RWY 09 (like in the incident flight) they will take TWY K, turn left unto H, turn right onto B and then the first right onto RWY 09. For some reason AF-1587 were on TWY J (south and parallel to TWY H, turned right onto B and (as if they thought they were on the "normal" TWY H) turned from B the first to the right, not onto RWY 09 (which from J is the second to the right), but onto....TWY H. Explicable, but not immediately excusable.

BR,

D Bru

I know there are always two sides to a story but this is unbelievable (in reference to the above video).

With the revival of the Concorde story elsewhere on the forum and the crash of 447, Air France needs to get their act together but probably won't.

It's a shame really because there are many people that work at Air France that sure seem to want to make it a safe carrier.

Half way through makes the point that the Airbus chief test pilot and bosses of BEA and the DGAC were at the same flying school in 1965 together...
Another old boys network..looking after each other?

Totally unacceptable .
 

After reading through the thread, I am sorry to say this is gross operational error.

Totally unacceptable from ATPL pilots.

Understandable if you are low time PPL pilot, and yes humans make errors, but these types of errors should not be happening on commercial flight deck period.

2 pilot crew, 2 pilots fail to recognize this? State of the art airplane. Please no excuses.

The traveling public deserves better.

AF Safety Culture
 

After reading all your posts and pretty much being aware of what AF does offer us in terms of "incident news", let me share this with you.

On one hand; it is pretty clear Air France has a Safety Culture problem, and I ain't telling you anything you don't already know, judging by all what we see and know.

It is quite common to approach Safety Culture as an Iceberg. What you see is only the small portion of it, the rest of the incidents, problems, cracks in the safety system are usually hidden.
This is because Air France was, until recently (I think, correct me on this one, but I think 10-15 years ago the French Government held 50 % of the shares) a French company, with a French public service company culture, with French Standards and French "wisdom", French know-how and French Standards. And, guys, I am not French, but they have been building and flying airplanes for quite a while! So they are good engineers too and they know it, and unfortunately, they are not used to others telling them what to do.

However, they have failed to adapt to what´s called "Bench-marking" and "Best recommended practices", Yes in part of an obvious "language barrier", but mostly because of a cultural barrier and a failure to accept that times have changed and that standards are not only French, but worldwide. And excuse me for saying this, but standards are also Anglo Saxon, namely British (who have a very developed and mature Safety Culture), American (Trend setters and the largest regulator worldwide) and Australian, among others (Germany, Netherlands, Canada and a few others).

Air France Safety Culture needs to be completely overhauled, with clear lines of what´s called a "Just Culture" being drawn. Air France needs to change into a "world class" airline and not only a French Class Airline, as tough as it might be to accept, they will have to accept to speak better English on the radio and conform to International Best Practices, be them Australian, American, German or Ugandan.

And for this, you need to go on hard-talk with Unions and major stakeholders in the company. And on this matter, I'm not quite sure they really want to do it , so hopefully, a few guys inside AF can realize that things have changed.

Thank you and Merry Christmas to yall. Safe flying to everyone...

I would like to know what the "incident" reporting standard is in order to determine whether AF has a Safety Culture problem. Not defending AF, but recent incidents of cockpit fumes with Germanwings and LH crosswind landing in HAM showed me that a certain hush hush mentality exists in Germany.

Looking at my airline, we have incidents from altitude deviations (or level busts) to nav errors and runway incursions. Do we have a "Safety Culture" problem? Not according to the FAA. Sh!t happens on the line, and no one can't tell me that LH, BA, VS etc. are immune from things going wrong. It depends if and how one reports it. Since this is a mainly British/US bulletin board, I am not surprised to sense (a little) bias. :yuk:

In other words: My poo doesn't stink. :rolleyes:

Hi,

Squawk7777
Just curious .. how many passengers and crews your airline has kill during the last ten years ?

look at American Airlines, US Air or Swiss(air) for example. Sometimes people get lucky, sometimes not. The number of pax killed does not entirely reveal the "safety culture" picture. It much more complex than that.

Deaths related to flying hours may not be a perfect way to give an operator safety rating. However it is something that is difficult to hide and for practical purposes is an excellent guide.

Not sure I agree with you on that. I had the pleasant near death experience by flying with a now defunct Mexican airline called Aerolineas Internacionales. Perfect safety record. On paper. Am still amazed that this airline did not kill any pax.

Talk to contractors that fly for a large airline out of the Korean Peninsula. Most of them will admit (after a few hops-related beverages) that they can't explain the good safety record. It's all relative.

7777,
There is a lot of truth in what you say,but I did say the system wasn't perfect. The best thing about the statistical method is that fatal air accidents quickly become a matter of public record. Even those not in the business have sufficient information to avoid airlines with higher than normal deaths.

The standard of airlines that are unsafe but with no fatal accident is mostly hidden and when it isn't, it is subject to perception. Those in the business, like you and me, have more information and avoid these airlines.

Squawk7777, bull's eye on that one!

You are so right, one of the roots of the problem in AF Safety Culture is what you just said, the reporting culture. I am not so sure what their standard is over their reporting policy over there, but after working in 3 continents, they are all very different. In Asia, some airlines would require mandatory reporting of exceeding of 30 kts during taxi, with disciplinary action if it was found it was a violation, whereas in North America, it would not trigger anything, hence people would less likely report it (in North America)

This is what I mean by "French Standards". There are no more "National" standards in this business, everyone pretty much has to abide by IOSA as the golden standard of Operational Safety, and regulators are more and more aligning flaws and caveats between their regulations and "world class" or international best practices in terms of SMS, FRMS, NOSS and all the shenanigans...

"Safety" is an instantaneous compilation of results. As such, it describes very little, and is used in contextual ways to placate fear, or sell stock.

In a cultural context, there are better ways to get a handle on performance, better still, to develop a culture that respects and mitigates RISK. Open and free reporting, (disclosure), internal and external, gives sufficient data to predict performance.

There is no "final score", and safety must describe 'in progress' all facets of risk.

In a setting of performance analysis, risk analysis can beneficially permeate the culture, and set a system wide 'tone'. Unfortunately, some companies manipulate, or ignore, best practice. Any principal officer who uses the word "luck" has provided a clue to the ID of such a firm...

Lyman :agree with you except on one thing : Luck does plays a role , always did.

Taking AF ( but only as an example , could take another airline ) was there anything controlled that prevented Toronto to become 200+ casualty instead of zero ?, same could be said for Habsheim, Brest or Pau more recently )

Been long enough in this business to know you can pile up statistics anyway you like , can hide anything you like or boost anyhing you like using numbers .

Safety is a culture, an immaterial thing, not easily translated in a mathematical formula.

clippermaro : you are right on the mark this old culture is more AF than : "French" . Other French airlines have not necessarily kept the same culture ( Air Carraibes comes to mind) although other still do.
The French air Force is not at all like this anymore since a long time .

A synonym for safety is care. Luck runs two ways. If care is lacking, one hopes for good luck, and banks a greater net profit. If one takes care, there is less money in the bag.

Remember the catch phrase, "With service to London, Paris, and Johannesburg."

It is a service industry. Such a concept is open to interpretation in its pursuit.

When BA038 crumpled, there was mystery surrounding the problem. Prior to a found cause, United discovered a paper problem with fire bottle 5 in the hold of some of their 777 fleet. They ordered an immediate inspection (of all 88 aircraft) including cancellation of several revenue flights. The inspection was mundane, and turned out to be deferrable.

There are other examples with other airlines, but a pattern of care develops, and some people notice....

ATC Watcher, yes, indeed it is a matter of organizational culture rather than national culture, on the provision that National Culture does influence the organizational culture, which in turn is unique.

One thing we are all missing in the discussion here is the role of the Regulator and its interaction with AF. In all fairness and without apportioning blame or drawing conclusions, I think there are tangibles signs of either negligence from the French CAA in their oversight of AF or there is a biased relationship due to years of doing things in a certain way (i.e. retired AF employees going to the CAA and the resulting conflict of interest).

In any case, the Regulator here has a major role and has clearly not addressed the problem correctly.

Lacey was talking very properly and technically about "identifying and mitigating risks", and couldn't agree more with you in that this is what safety is about...

Years ago I remember an accident in Mexico, where a DC9 was involved in a Runway Excursion. This airline (I won't say names) was in turn in a code share agreement with a major US Airline. Because of this Code share agreement and in order to maintain it, the US investigators from this airline conducted an independent investigation of the accident and concluded something that may help your thinking on this topic.

"Although XYZ Airlines is a Safe airline, judging by the audits conducted by the National Regulator (the Mexican CAA), the US FAA, ourselves (being them the major US airline) and Insurance brokers, XYZ Airlines does not have a Safety Culture".

In other terms, you can be a Safe organization, as shown in audits, but you may not have something more important that is a safety Culture.

Think what Qantas did after the QF32 incident in SIN, they decided to ground their whole A380 fleet until the manufaturers could pinpoint the problem. This is the reflect of a mature and predictive safety culture. You can draw the conclusions on AF yourselves...

I am not still sure if it relevant but I would like to put on the table the idea of national mentality of country and its impact on safety. Maybe the problem is with the French mentality rather with AF SOPs. The captain is always right and of course the union will make sure he/she is even if he is not.

ZBMAN,

Having lived in both Belgium and the UK there is a remarkable difference in the mentality of higher education professional for instance. In Belgium a student takes a lot of pressure for petty issues like poor language skills on a marketing report - without mentioning the instructors had an "I am God" syndrome, and that at a national diploma level. In the contrary in the UK professors are far more approachable, if one can say so, and they tolerate arguments poor language skills if the student's idea are correct.

I was also told by a UK professor that some national mentalities believe they are have the best competence in the world and they need no coaching. Hence the comment was generated by my experience in the French education system so hardly a racism rather a justified opinion. And please note that I do speak French fluently, I do enjoy my time in France and spending time with its nationals.

I would be glad to read your definition of racism and how my comments and others to this and the others AF threads relate to it!

I doubt there is, and the views from "outside" are mostly myths (be dissing the French I am telling a "good" story about myself and my cultural background).

But there are corporate cultures and cultures within professions. I think it's much more productive to discuss or analyze culture and "mentality" on that level.

The different national cultures were explained to me by a German Airbus test pilot as follows:

"Let's say we sell the Brits, the Germans and the French the same type of aircraft. The Brits decide they want to use it for a particular purpose, so they check the Flight Crew Operating Manual for any limitations. If there aren't any, they go ahead and do as they wish"

"The Germans also decide that they want to use the aircraft for the same purpose, so they look through the FCOM for the relevant procedure. Finding none, they conclude that they cannot do it"

I then asked him "But what about the French?"

"They just say «What manual?»", was his reply!

I am once again sadly surprised by the xenophobia by certain "so-called" professionals. According to BEagle all French pilots should not be trusted, only the Germans and the British are the supreme commanders of the skies. (Seriously mate, had a bad day, lately?) How can this board even consider using the title professional with certain comments like the above?

For all those that disagree, another indicator of pprune's xenophobia is the yearly occurring "non-English" ATC thread, that occurs with such regularity that one can sing "Alle Jahre wieder". For some odd reason, I haven't seen one yet that doesn't accuse France. It makes me laugh, since my international flights go into Central and South America, and according to most monoglots roaming this board I am gambling with my life. None of those internet tough guys seem to dare to put their logic (whether I agree to it or not) into the Latin America forum, since this is an area quite larger than Europe.

To go back to the original topic "another AF incident", it lacks any comparison to one of its European competitors since we do not have complete data of incidents (including AF). No one can convince me that airlines like LH, BA, VS, etc have perfect ops every day. Just because an incident makes a news story it does not reveal the complete picture of that airline and even of its competitors or even the national mentality. As we know, national sentiments can go both ways. :ugh: (as can luck)

Merry Christmas!

Plenty of BA-related incidents on AvHerald, like this one

Incident: British Airways A321 at Edinburgh on Jun 16th 2012, unreliable airspeeds

(loss of airspeed indication in a FBW Airbus, sound familiar?)

yet they don't seem to be characterised by gross operational negligence, like those of another airline one could mention.

because it doesn't happen or because it doesn't get reported?

Response to above.


It appears that the NTSB believes as I stated above. Sorry that you and FireFlyBob disagree with them.

As a result of the investigation of this accident, the National Transportation Safety Board makes the following recommendations:

To the Federal Aviation Administration:

Require that all 14 Code of Federal Regulations Part 91K, 121, and 135 operators establish procedures requiring all crewmembers on the flight deck to positively confirm and cross-check the airplane's location at the assigned departure runway before crossing the hold short line for takeoff. This required guidance should be consistent with the guidance in Advisory Circular 120-74A and Safety Alert for Operators 06013 and 07003. (A-07-44)

But the NTSB has to produce endless lists of checks. if they go for KISS then any fault that occurs will be countered by lawyers, "You didn't tell them" eventhough the response is, "They are/were pilots, employed by a company with legal obligations blah blah." If you have laid out a zillion rules and something went wrong, "We did all that we could."

For NTSB and similar organisations, this kind of action is a SOP.

Not that simple. At the outset of most great enterprise, energy is directed at performance, not product. Then the product takes precedence, then ultimately the result of product, profit.

Along the way, one ceases to do one's best, and starts to do what is necessary, then what does not draw attention to one's self.

In this vacuum of integrity, the format must produce laws, SOPS, and training to entice performance. Then the regs cease to demand performance, and simply serve as warning to meet minimums.

What follows is inevitable, blame replaces integrity, and profit replaces performance.

Culture not important? Whether corporate or societal, culture is everything.

To ignore that is beyond risk, it is an invitation to disaster.

I’m on the same page as Lyman.

What’s dangerous about this territory? Safety does not care about culture or political correctness. Anything not working to enhance safety should be named, be it even social culture. If you can’t cope with that, leave this profession, because you start being a liability to safety.

We should be allowed to point out weaknesses in company culture or manufacturor design without having the usual suspects to start trash up the discussion with their lobbying bs or the other protagonists bringing up political correctness to shut it up.

Genuine safety has little to no space for such oversensibilities.


On another note, I am with piltdown man concerning the SOP/briefings overkill of today. SOPs are necessary, but not for every obvious little move in the cockpit, please.
And the modern briefings ……. They end up like life of an old couple: She’s constantly babbling the same stuff she has for the last thirty years, and he’s constantly uttering “yes dear” without listening the last thirty years.
Our constant “checked, checked, checked” is no better.

Stick to the differencies, to the unusual threats and you will have my full attention.

Stacking up the AOMs with more and more SOPs just to cover any CP or company lawyers is another nuisance. It rarely enhances safety, on the contrary, it increases workload in the cockpit and is counterproductive.
You can call a runway three times and have it confirmed by the PNF another three times, if its paired with todays a$$ covering, "standard call and don't you dare get one word wrong in the phrase" mentality there will be just as many runway incursions if your mind is stuck in the AOM instead being outside in real life.
That seems to get lost.

It would be interesting to compare the level of social diversity within AF to other european airlines.

I don't think that it is xenophobic or French bashing in anyway to make it clear that the record of Air France over the last 30 years has been unacceptable. Air France have not matched the safety standard set by other equivalent airlines regulated within Europe. Whilst Korean air, who have a similar record, make clear steps to resolve their issues, it appears to me that Air France wish to pass the buck wherever possible.

Hi everyone,

Airbus is currently developping the TOS (Take Off Securing) function that will normaly prevent that kind of mistake. These incidents occur more than mentionned in medias.

This function was first implemented on A380 as an option and will be basic on A350. The aim is to give alerts - depending on the situation, Master Caution (amber) or Master Warning (red) - providing crew awareness like 'ON TWY', 'NOT ON FMS RWY', 'FMS SPEEDS DISAGREE', 'T.O SPEEDS NOT INSERTED', ect..

Let's hope that these function, which normaly must never appears, will avoid any take off in bad conditions (wrong RWY, invalidated take off speeds, ect..). However, I am wondering how is it possible to make this mistake. I did not fly into each ARPT in the world but it seems to be hard to not make the difference between RWY & TWY as lights and markings are different.

Regards

About Culture:

I am probably going to say this clumsily, but here's my first stab at this.

When you are inside of your own cultural assumptions, it can be difficult to see what someone outside of your cultural assumption sees.

The "face saving as a primary norm" culture is found in varying degrees in Asian countries. It is not unfair to consider this a culturally imbedded organizatinoal norm, which unfortunately is diametrically opposed to the humility and self-examination (and admission of fallibility) a sound safety culture requires in a successful organization. Lest any of our non-Asian compadres feel smug, elements of this world view can and will crop up in organizations based elsewhere. I ddn't grow up in the great 'save face' culture but was exposed to it early, in my teens while living in Asia.

Get mad at me for stereotyping if you like, but consider that when I returned to Asia in my early 30's, I got one of those cultural appreciation briefs and training that highlighted precisely that: the whole "save face" cultural norm that was pervasive in Japan.

Hold that thought for a moment.

There is a common sub culture, or set of norms, among high perofrming, type A personalities that promotes self-belief and self-confidence. Taken too far, it leads to narcissicism, which I have seen lead to some remarkable "blinders on" failures in self-awareness. From where I sit, this approximates some of the more dangerous elements of the "save face" style and attitude.

A cliche related to this is "better to die than to look bad" attributed to fighter pilots. The related sub genre I am more familiar with is the "aircraft commander/Captain is God of his cockpit/flight deck" attitude

I was swimming in that particular sub-culture in my first squadron, about the time CRM and ACT was taking hold for serious in the USN. I think it took most of a generation to get our service to change norms and cultural assumptions, thanks in part to repeated emphasis from the highest echelons of command and a well funded safety arm. Thanks are due to the airlines and what they learned, and lessons they shared, many of which were written in blood.

I will suggest that it takes a cultural baseline of humility and acceptance of fallibility to allow such changes to come to fruition. That seems to me to be where a crucial problem in the "save face" cultural baseline resides.
It's a higher hill to climb to get to the same peak performance.

Arrogance, be it personal or cultural -- or maybe a bit of both -- is an obstacle to a solid safety culture. Yes, it can happen to any of us, anywhere. Problem is, in order to fly well, you have to have the self confidence to believe you can do something, to go ahead and master it, and to keep doing it. From self-confidence to arrogance to worse isn't that far of a progression in each step.

What I am trying to point to is that some baseline cultures (before you even get near an aircraft) present additional obstacles to the standard challenges all pilots share.

What's this got to do with Air France?

If you are inside whatever "French" cultural assumptions are, how clearly can you see your own cultural assumptions, and thus potential impacts on organizaitonal safety culture? (Fill in the blank with a given flag carrier if you like, and see how well it fits).

That, I think, is what some of the posters up above us are getting at in re culture.

OK, standing by for rocks to be thrown.

Think you nailed it. . lived 12 years in France, loved it, but I could still be frustrated by some aspects of the French mentality. I can certainly offer "being French" as a casual factor in a fairly high number of French accidents. . .. . . but, as you say, we are not allowed to say that in this blinkered/politically correct world we habitate.

The problem for me with the clear issues that Air France have is not cultural to the country at all, but is cultural to the airline. Everything I read to do with the fatal accidents which Air france have had indicate that they can not accept any responsibility, they always try to place the blame elsewhere i.e. with Airbus, or continental.

Although I am sure that a lot has been done within the company behind closed doors to address the problems, I struggle with the fact that these are major safety issues and the problems need to be dealt with transparently. Pilots need to be able to look at Air France as an example and be able to say this is what they have done to deal with the situation. Korean air can hold its head up high and say this is what we did to create a safe airline. From what I can see at the moment Air France can not.

Having said all that the IOSA report must have been acceptable enough that other Airlines are prepared to code share with Air France. So they must basically be following international standards. I'd prefer if everything was clear though.

IOSA...

if the assumption of "goodness" is determined by the outcomes of the IOSA report... beware. IOSA looks primarily at documentation rather than implementation, and little meaningful correlation of actual system behaviour vs reports is conducted. What do I mean by this? The IOSA audit may find that the SMS is fine, however the incident reports do not reflect the policy of reporting vs QAR data capture... therefore there is a variation between the policy and reality/practices. IOSA AO are additionally paid by the parties that they are auditing of or for, and therefore have a dog in the fight, which is problematic. This may be well managed as a Chinese firewall, or not. The proof is look which airlines have gained glowing IOSA audits, and after you have stopped rolling around on the floor laughing, consider the implications.

If IOSA are using data, documentation, and foregoing implementation and correlation, then the product is nothing more than forensics without precedent failure. Is there a better synonym for 'standards' than minimum?

It is no mistake safety is best described as cultural in nature. It begs a synthesis of performance plus, and a format that is a foundation for surpassing achievement levels that are merely "satisfactory".

Safety is organic, and wants the kind of attention given to social endeavours.

The most important ingredient, therefore, is leadership.