AF447 wreckage found

[before landing check list]

PILOT ERROR: Air France Jet Plunged Into Ocean Because Pilots Screwed Up

I just found this today. I have no idea if it will help or not.

I think you guys can brain storm all you want over the fine points why the computer and or indications did what they did. However the bottom line is either the pilots had mucked up data for whatever reasons and for that reason could not fly the aircraft out of the situation or the freaking system would not let fly the profile what was needed to escape the bad situation.

If we are encouraged to believe that the THS reacted to 'noseup inputs' by pitching up, why did it not in turn respond to 'nosedown inputs' by pitching down?

This is not a problem for non FBW aircraft. I say again we are so far ahead of the game we have lapped ourselves and are now behind again.

I will give the pilots the benefit of the doubt on their flying (not managing) skills. I have to ask again, do you want to be able to fly an aircraft or do you want to fly a system? Please do not give me a lame excuse about how fine the system is, just answer the question.

[DozyWannabe]

Originally Posted by jcjeant

Airbus is not better (they always stated before 2010 that stall training was not needed)

I think that was a misconception widely held by the industry as a whole, and not specific to Airbus in particular. It certainly looks like AF are going to have to pull their socks up though...

[EDIT : @before landing checl list - I think that's a terribly poorly-summarised article which doesn't even bother to translate what's being said into layman's terms - the whole thing has been reduced to an inaccurate soundbite. ]

[jcjeant]

Hi,

Found on a french site .. the synthesis of the press meeting (in french)

15h04: «Il est nécessaire d'examiner la façon dont est organisée la sécurité des vols chez Air France» affirme le directeur du BEA.
Nouvelle critique sur la coordination dans cette compagnie aérienne.

15h02: L'enquête continue, déclare Jean-Paul Troadec, directeur du BEA. La difficulté réside dans l'analyse du comportement des pilotes, d'où la création d'un «groupe facteur humain».

15h01: Recommandation analogue sur la balise de détresse, qui est un instrument pas très fiable et qui se détruit facilement, dit le directeur du BEA.

15h00: Le directeur du BEA Troadec évoque la difficulté à localiser les épaves d'avion, et émet l'idée de multiplier les données sur les localisations des avions. «il faut réduire au maximum la difficulté de localisation».

14h59: Recommandation sur l'imposition d'enregistrement de nouvelles données

14h58: Recommandation sur les utilisations plus strictes des données des enregistrements de vols.

14h57: Il y a un besoin d'enregistrement des images de la planche de bord, dont le radar, affirme le directeur du BEA.

14h56: Il y a besoin de réaliser une étude sur la présence d'une évaluation d'incidence accessible

14h55: Recommandation sur la suppléance du commandant de bord

14h54: Les recommandations sur l'exploitation, dont le renforcement la compétence des pilotes en pilotage manuel en haute altitude.

14h53: Les recommandations concernent l'exploitation, la certification, les enregistreurs de vols, la transmission des données de vol.

14h52: Il parle de précédentes recommandations, dont les sondes Pitot.

14h50: Le directeur du BEA, Jean-Paul Troadec reprend la parole et ennonce des recommandations de sécurités.

14h50: «Pour essayer de comprendre les actions du pilote; un groupe facteur humain va être créé» dit Alain Bouillard

14h48: Alain Bouillard, du BEA dit que l'équipage et sa formation est conforme (la formation a depuis été modifiée). Il n'y a pas eu de répartition claire des tâches des pilotes. Il pointe les défaillances des pilotes.

14h47: Aucun message de détresse n'a été émis par l'équipage, dit Alain Bouillard du BEA.

14h45: Les pilotes affirment ne plus avoir d'indications valides. Une action à piquer est alors réalisée. L'avion est à 4.000 mètres à 240km/h; L'incidence est toujours à 15°

14h44: Incidence passe à 40°. La chute est 11.000 pieds minute. Les moteurs sont en pleine poussée.

14h43: L'assiette et l'incidence sont à 16°. Les alarmes s'éteignent car les données sont considérées comme invalides.

14h41: Maintien de l'ordre à cabrer du pilote. Les pilotes ne voient pas la situation de décrochage.

14h40: L'assiette progresse au-dessus de 10° et l'avion prend une trajectoire ascendante. L'avion monte, avant de descendre brutalement.

14h38: L'agent commence à détailler les problèmes survenus, dont le givrage des sondes pitot , les alarmes de décrochage qui résonnent, les ordres à cabrer du pilote.

14h35: Récit du début du vol par Alain Bouillard, du BEA. Deux pilotes en cabine. Vitesse normale de croisière. L'agent du BEA retrace les éléments déjà connus du vol d'Air France.

14h33: La conférence de presse du BEA a commencé au Bourget. Le directeur prend la parole, regrettant le traitement médiatique fait sur la catastrophe

[ilesmark]

"Sebaska wrote at #2233 (I don't have the quote facility for some reason)

RWA

Quote: If we are encouraged to believe that the THS reacted to 'noseup inputs' by pitching up, why did it not in turn respond to 'nosedown inputs' by pitching down?

It was explained to you already, yet you choose to ignore that and champion your pet theory of "cover up".

"

Where was this explained already, Sebaska? I have looked and I can't see any answer to RWA's point. I think it's a valid one.

[bearfoil]

Without any new evidence, the crash becomes more an exercise in politics, and authority.

Perhaps the bottom line is how much authority (control of evidence) should any entity possess which has a commercial interest in the outcome of their investigation?

DOZY: As a sw boffin, do you expect much of what is needed for an understanding has a particular timeframe?

I think the window around a/p loss, since this is the point at which the vulnerability was highest? If the PILOTS are as described, what is the point in a retrospect of STALL?

How did this START?

[jcjeant]

Hi,

I think that was a misconception widely held by the industry as a whole, and not specific to Airbus in particular. It certainly looks like AF are going to have to pull their socks up though...

Well ... the aircraft involved in the crash is an Airbus property of AF and piloted by AF pilots so far I know

[jcjeant]

Hi,

Some comments about extracts of the press meeting:

14h56: Il y a besoin de réaliser une étude sur la présence d'une évaluation d'incidence accessible

2:56 p.m.: There is a need to conduct a study on the presence of an indication of attitude

Those type of instruments are already available ... but were not installed on the AF447

15h02: L'enquête continue, déclare Jean-Paul Troadec, directeur du BEA. La difficulté réside dans l'analyse du comportement des pilotes, d'où la création d'un «groupe facteur humain».

3:02 p.m.: The investigation continues, said Jean-Paul Troadec, director of BEA. The difficulty in analyzing the behavior of pilots, hence the creation of a "group human factor".

The analyse of the pilot behaviour is not so difficult .. when you know that the BEA itself show in his synthesis the "lack of proper training" of the AF447 pilots

14h33: La conférence de presse du BEA a commencé au Bourget. Le directeur prend la parole, regrettant le traitement médiatique fait sur la catastrophe

2:33 p.m.: The press conference began in the BEA Bourget. The director speaks, regretting that the media coverage of the disaster

First at all ... in France the press is free and secondly .. the press articles were based on leaks from the BEA
Before take care of the press .. it's better for BEA to give a look at their personnel !

[jcjeant]

Hi,

Full report available: (so far in french only)
http://media.webcastor.fr/web/bea/f-cp090601e3.pdf

[AlphaZuluRomeo]

jcjeant, take care when translating:

14h56: Il y a besoin de réaliser une étude sur la présence d'une évaluation d'incidence accessible

2:56 p.m.: There is a need to conduct a study on the presence of an indication of angle of attack (not attitude)



About the group: question is why the stall alarm was ignored, IMO.

About the leaks: from the BEA ? Sure of that ? Of from interested parties (company, manufacturer, government...) who had access before the general public ?
Do you search for facts, reality, answers ?

[xcitation]

Synthesis Note

Nothing new. A "qui" typo on the english version that should have been caught by the proof readers, a bit sloppy from an organization that is detail focussed, surely a simple spell check would catch it?

Safety Recommendations

Some odd grammer but readable. All looks good addressing the areas of serious concern that we have read in the forum threads. To that extent it is all consistent.
However it still does answer why the pilot inputs of generally nose up which appear to contradict the PFD. Why input stick back when pitch +16 and below Vs with TOGA thrust and N1 near 100%. Perhaps we will never know as we can't see exactly what the flight instruments showed. This appears to be addressed in the remarkable suggestion in the safety recommendations. Is this formally recommending cameras on the flight deck?

Images recorders

One recommends that the regulatory authorities require that aircraft undertaking public transport flights
with passengers be equipped with an image recorder that makes it possible to observe the whole of the
instrument panel. Another recommends defining strict rules relating to the use of such recordings.

Flight parameter recordings

There are two recommendations on recording additional parameters.

[DozyWannabe]

Originally Posted by bearfoil

DOZY: As a sw boffin, do you expect much of what is needed for an understanding has a particular timeframe?

Well, from a software perspective, what you'd need to do is load up a test rig made up of the exact hardware installed on that aircraft with the exact software installed (down to point releases), apply the DFDR data to that test rig's inputs to see what the software and hardware does - then repeat this test anything up to hundreds or thousands of times to see if any anomalies appear. I suspect this would not be a small or inexpensive undertaking, but it would be do-able.

How did this START?

It's looking very much like an inappropriate response to the situation as it developed, starting with the nose-up inputs shortly after FMS disconnect, then progressing through selection of TOGA and the later aggressive and maintained nose-up inputs all the way down, and it wouldn't be the first time it has happened (as I've always said, I think this was another Birgenair-type situation).

Way back when I started commenting on these threads earlier in the year I said that unreliable instrument readings in the wee hours at night, in IMC with unsettled weather hundreds of miles from land was a nightmare situation for any pilot to confront, and that any findings of mishandling on the part of the pilots *must* take this factor into account, and this is why I got very agitated when people said that by saying software failure was unlikely to be a cause I was blaming the pilots.

Lack of training appears to be a significant issue here, along with poor CRM practice when it comes to rest periods. It would appear that the ITCZ is a known problem area when it comes to aviation, and many pilots on the thread have expressed the opinion that they would not have left the two F/Os in charge until safely out the other side.

Colganair 3407 was the wake up call that the airline industry had bred complacency in two distinct areas, one of which was the effect of fatigue and the other was poor recognition of stall conditions and application of the correct response to those conditions - but that investigation was still ongoing when AF447 crashed and the final NTSB report not released until February 2010, 8 months after AF447.

In short I think AF447 was a "perfect storm" of the problems within aviation. Birgenair and Aeroperu had shown what could happen if the pitot-static system was compromised, but both of those incidents happened in the climb phase. Not much thought was given to what would happen if something similar happened at cruise altitude, with the attendant limits on possible escape procedures. Airlines had been training pilots to respond to approach to stall and the warnings generated without getting into what would happen if you were to actually stall, how to recognise it and - crucially - how to get out of it, because it requires going against the human instinct to cram on power and pull up when the correct response is actually to get the nose down and hold it there until the speed comes back and the wings are flying again. AF also deserve to come in for criticism for failing to expedite the replacement of pitot tubes which were known to have problems.

@jcjeant - if you're honestly suggesting that airlines were training their Airbus pilots on approach to stall only and the rest of their crews were getting full stall recognition and escape training, I think you need to get some perspective.

[TioPablo]

BEA´s Safety Recommendations

Training for manual airplane handling

The first recommends that the regulatory authorities re-examine the content of training and check
programmes and in particular make mandatory the creation of regular specific exercises aimed at manual
airplane handling. Approach to and recovery from stall, including at high altitude.

As B4-LandingChkList , bubbers44 and others pointed several posts away: More stick time…
The question is who is going to pay for that? And… How is that redefinition of training going to look like?
Bubbers44 said gliding isn´t cheap; well prolly companies should pay that kind of training. Much more cheaper than a hull loss anyway.

Angle of attack measurement
This recommends that the regulatory authorities evaluate the relevance of requiring the presence of an
angle of attack indicator directly accessible to pilots on board airplanes

Well Airbus… Begin asap with it methinks...

[Man Flex]

No conspiracy theory. The situation was mishandled by the crew leading to the aircraft departing its flight envelope.

Now the investigation will focus on the human factors involved and attempt to resolve why they did what they did.

[000tfm000]

On a very quick skim-read of the French text, two key questions are:

1. Why did it start to go wrong?

2. Why was it not corrected?

As to 1: notwithstanding the difficult conditions I am afraid it does rather look like pilot error in the sense of being a combination of ill-discipline in the cockpit and bad training. If I have understood correctly, the PF and PNF had received no training in how to deal with inconsistent IAS inputs at high altitude, or in manual flight at high altitude.

However, as to 2: IMHO the full CVR transcript shows that the systems were in large part to blame. The passage from 2:12'37 to 2:12'44 is tragic and shocking in equal measure. At the start of this timeframe (i) the PF was (for once) pushing forwards (ii) the aeroplane was in a stall but (iii) the stall warning was still silent. My poor translation is that the PNF tells the PF to "descend! descend! descend!" The PF says "That's what I am doing." The Captain intercedes "No, you're climbing". The PF says "I'm climbing [meaning - "you think I'm climbing?"], okay, I'll go down".

At precisely this point, his nose-down inputs stimulated enough speed to trigger the stall warning. The captain's next remark is "This isn't possible." His bewilderment is unsurprising.

Thus the PF's correct nose-down inputs were punished by a stall warning; his wrong nose-up inputs were rewarded by the stall warning ceasing.

The instruments thus played a cruel, Pavlovian trick on the pilots which IMHO goes a consdirable distance towards exonerating them.

I don't think this is sufficiently emphasised in the report.

[levelvibes]

Copilot´s training

Who can please shed some light on the copilot´s deficient training the BEA report states.

"The copilots had received no high altitude tr aining for the "Unreliable IAS" procedure and manual air craft handling".

I find it hard to believe this. Isn´t this training absolute standard in any simulator training of any serious airline?
Am I missing anything?

Thanks

[Hyperveloce]

Originally Posted by levelvibes

Who can please shed some light on the copilot´s deficient training the BEA report states.
"The copilots had received no high altitude tr aining for the "Unreliable IAS" procedure and manual air craft handling".

The 3rd interim report says that none of the two copilots had received a proper instruction/training for
- manual A/C piloting at high altitude (see PF's large amplitude inputs in roll and pitch above 35 000 ft)(I am also very disturbed by this !)
- UAS procedure at high altitude (one of them had received a training for UAS at low altitude, where the pitch was higher, in the order of 10°)
The CVR also shows that there was no clear attribution of the roles by the CDB when he left the cockpit, and latter, that the cooperation between the two copilots was not very good

[Halfnut]

AF447 Interim Report In English -

http://www.bea.aero/fr/enquetes/vol....let2011.en.pdf

[bearfoil]

Hmmm. Claiming the a/c behaved as directed after this accident was under way is misleading, if not a direct fraud. No one to this very day knows what to expect after LOC ending in Stall, yet that is the focus of the BEA recommendations? Confusion on the flight deck? Christ, does any pilot take that as a serious critique of these guys given the circumstances?

The induction of this LOC is virtually ignored. The Public is to accept the outrageous nonchalance of this outfit, and be satisfied with a conclusion and blame prior to the finish of the investigation?

I suppose we could say that the release is intended for public and lay consumption, hence the simplistic opinion and utter lack of evidence.

But that leaves the Public with but one source of critical knowledge, a source with a financial and commercial interest in the outcome. I cannot abide "International" accords, when they are merely political, but a proper and objective source of multidisciplinary critique might be an alternative.

Who Guards the Guardians?

[bearfoil]

Hyperveloce

yes. This fact screams complacency, and negligence. If accurate, then any criticism of the pilots stops well short of the actual responsibles.

bear

[Lonewolf_50]

bear, one may make some criticisms of various members of, and actions of, the flight crew without precluding criticisms of the others whose contributions to this event, via their roles, actions, and inactions were prelude to that dark and stormy night.

Let's not raise a false dichotomy.

I estimate that the key to your objection is the way that cause factors are communicated.

The vague term of "pilot error" has so much currency, and so dubious a meaning, that it can be misleading or be no more than a fig leaf.