AF 447 Thread No. 8
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PJ2
The example of Fukushima is an interesting one and here in Japan the revelations are so enormous that they would take your breath away. The level of incompetence, nepotism and sheer mendacity is just staggering and the organisation seems to have learned nothing. It is also endemic throughout the whole power industry. How is this relevant to AF447? I do believe it ties in with what I have been saying about corrupt cultures - it is not just the drive to save money but that the organisational culture is fundamentally skewed. Lyman's comment about on the line is also very relevant. It is up to senior pilots to set the examples for others to follow. If the exemplars are professional and ready to help then the line pilots will mostly follow that lead. There also needs to be a certain level of ruthlessness so that sub-standard or pilots with under developed skills are not allowed to fly. This I believe very much links in with the cost saving ethos you identify. It is cheaper to allow them to continue flying than to correct the problems or remove them from danger.
The example of Fukushima is an interesting one and here in Japan the revelations are so enormous that they would take your breath away. The level of incompetence, nepotism and sheer mendacity is just staggering and the organisation seems to have learned nothing. It is also endemic throughout the whole power industry. How is this relevant to AF447? I do believe it ties in with what I have been saying about corrupt cultures - it is not just the drive to save money but that the organisational culture is fundamentally skewed. Lyman's comment about on the line is also very relevant. It is up to senior pilots to set the examples for others to follow. If the exemplars are professional and ready to help then the line pilots will mostly follow that lead. There also needs to be a certain level of ruthlessness so that sub-standard or pilots with under developed skills are not allowed to fly. This I believe very much links in with the cost saving ethos you identify. It is cheaper to allow them to continue flying than to correct the problems or remove them from danger.
The past seems incredible, the future implausible.
Old Carthusian, et al, How is this relevant to AF447?
All that has been said or might be said about AF 447 or Fukushima, is in hindsight.
Are we really able to understand the situation as these people did at the time of their assessment and decisions?
If we are, then we must carry equal responsibility for not acting to prevent such disasters. No, at best we might say that our judgement was flawed, or more accurately that we lacked foresight.
Creating Foresight.
.
All that has been said or might be said about AF 447 or Fukushima, is in hindsight.
Are we really able to understand the situation as these people did at the time of their assessment and decisions?
If we are, then we must carry equal responsibility for not acting to prevent such disasters. No, at best we might say that our judgement was flawed, or more accurately that we lacked foresight.
Creating Foresight.
.
Last edited by alf5071h; 1st Jun 2012 at 01:28.
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I think it at times unfortunate that we humans have such an obsession with nomenclature, and identification. There is almost always a drive to synthesize a corporate culture that is monolithic, and a follow on to a former monolithic. This spills into the disciplines, and creates an inevitable conflict.
With great respect, it is at times also risky to create a new paradigm reliant on the creators of the old one. What lasts, what is resilience anyway, but time tested procedure that evolves, some times in spite of design, not because of.
We have a cross cultural habit of injecting useless traditions and prejudices into the new age, We fear the future, whilst we address it.
The soft sciences are so vulnerable to abuse, but here, I think a time out from that prejudice is important. As I said prior, we can create an environment for ourselves that promotes the human failings that we cannot discard. The secret is not to fight them, for they are who we are. Acknowledge, and look in the place where the problem is. At a time when leadership is rare, we have educated too many to assume its role, to our great hazard.
We encourage "outside the box" thinking, innovation, and analysis by the wrong people.
I promise, of all the "New" proposals I have seen, (business), there is a fanfare for the new, the new analysis, the new method. At times, when stupid things happen; the truly inexplicable failure cuts our project off at the knees, it is a human failing that has made it possible.
A healthy industry is not adversarial, not fearful, not greedy. Its inner bonds are strong (resilient?), its employees are secure, and specialists supported, and respected. So long as people are involved, it is crucial to support them, for in supporting ones employees, one makes possible great things. One cannot betray the people, as one would desert a machine, to labor on in darkness and obscurity.
The problem is a lack of leadership. The old ones know what it is, they are here, they have experienced the camaraderie and loyalty that come from a workplace that is kind, explicit, and honest. Not a desperate, snappish, and distracted struggle.
I have a tape of Feynman's last lecture... It was sublime.
Lighten the load, get a grip, and patiently recast the mission in the midst of its prosecution, It is a people business. The technology, as we see, is here.
Lose the fear.
With great respect, it is at times also risky to create a new paradigm reliant on the creators of the old one. What lasts, what is resilience anyway, but time tested procedure that evolves, some times in spite of design, not because of.
We have a cross cultural habit of injecting useless traditions and prejudices into the new age, We fear the future, whilst we address it.
The soft sciences are so vulnerable to abuse, but here, I think a time out from that prejudice is important. As I said prior, we can create an environment for ourselves that promotes the human failings that we cannot discard. The secret is not to fight them, for they are who we are. Acknowledge, and look in the place where the problem is. At a time when leadership is rare, we have educated too many to assume its role, to our great hazard.
We encourage "outside the box" thinking, innovation, and analysis by the wrong people.
I promise, of all the "New" proposals I have seen, (business), there is a fanfare for the new, the new analysis, the new method. At times, when stupid things happen; the truly inexplicable failure cuts our project off at the knees, it is a human failing that has made it possible.
A healthy industry is not adversarial, not fearful, not greedy. Its inner bonds are strong (resilient?), its employees are secure, and specialists supported, and respected. So long as people are involved, it is crucial to support them, for in supporting ones employees, one makes possible great things. One cannot betray the people, as one would desert a machine, to labor on in darkness and obscurity.
The problem is a lack of leadership. The old ones know what it is, they are here, they have experienced the camaraderie and loyalty that come from a workplace that is kind, explicit, and honest. Not a desperate, snappish, and distracted struggle.
I have a tape of Feynman's last lecture... It was sublime.
Lighten the load, get a grip, and patiently recast the mission in the midst of its prosecution, It is a people business. The technology, as we see, is here.
Lose the fear.
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By accident I came across this page dedicated to the explaining the problems associated with the pitot, and in particular the AF447 problem. It didn't take long to realize that most of what is there had been contributed by posters on PPRuNE.
Have a look, and you might find something of interest, or something you wrote.
Have a look, and you might find something of interest, or something you wrote.
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Final Report.
Although not admitted by some, we all know upset was initiated by PF.
Besides the recommondations already published at the publication of IR#3 (AoA indication, FDR, Manual Alt Training) there were valid questions still to be answered:
Press conference, 29 July 2011
IMO that could prove if it was (initially) unintended.....
For the first issue AF recently introduced the GATEKEEPER system.
The second part, I expect it is self-audit....which IMO is not 'healty' in aviation by definition.
Besides the recommondations already published at the publication of IR#3 (AoA indication, FDR, Manual Alt Training) there were valid questions still to be answered:
Press conference, 29 July 2011
Alain Bouillard .......
To try to understand the pilots' actions I have decided to set up a human factors group that will study the behaviour and the actions of the pilot, containing specialists in ergonomics, cognitive sciences -- psychologists, and doctors specialised in aviation.
We are continuing to examine the pilots' seats to try to understand if the adjustment could have influenced their inputs on the sidesticks.
.......
To try to understand the pilots' actions I have decided to set up a human factors group that will study the behaviour and the actions of the pilot, containing specialists in ergonomics, cognitive sciences -- psychologists, and doctors specialised in aviation.
We are continuing to examine the pilots' seats to try to understand if the adjustment could have influenced their inputs on the sidesticks.
.......
Jean-Paul Troadec - ....
There are two themes which are, which we could describe as doubtless the most systemic.
That is to say that, we think it is necessary to examine the way in which flight safety is organised at Air France and the way in which the monitoring actions of the oversight authority are conducted.
.....
There are two themes which are, which we could describe as doubtless the most systemic.
That is to say that, we think it is necessary to examine the way in which flight safety is organised at Air France and the way in which the monitoring actions of the oversight authority are conducted.
.....
The second part, I expect it is self-audit....which IMO is not 'healty' in aviation by definition.
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A33Zab;
Thank you for the link to the text of BEA's Press Conference on 29 July 2011. I found this little tidbit interesting (my bold):
Thank you for the link to the text of BEA's Press Conference on 29 July 2011. I found this little tidbit interesting (my bold):
Alain Bouillard No call was made for the unreliable airspeed procedure - unreliable IAS - which requires checking that the autopilot is OFF, that the auto-thrust is OFF, that the flight directors have been shut down, and that the pitch attitude for this procedure is 5 degrees and that engine thrust is on CLIMB.
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HazelNuts39
I am not sure your point. If it is to emphasize the lack of proper procedures, you have. Something is missing, and it is exquisitely salient. The speech is given after the passage of time. Without a deliberate attempt to frame his comments in the context of the pilots situation it is misleading, to say the least.
Naturally, I will claim it is deliberate. It is.
He uses terms not in existence at the time of the crash. His summary is selectively exclusive, and presumptuous. Human nature being what it is, virtually everyone reading his text will absorb it in ignorance of its subtle purpose.
There was discussion of Pitch and Altitude, and immediately. The determination of UAS was made after 447 was on the bottom, I propose the crew were unaware of it until seventeen seconds after its appearance, and longer than that after its actual start. This presently can not be discounted, and bias and passion do not count as evidence......
Everything that is officially released, including data favorable to the crew,
must be received with profound distaste, and without prior thought....Absorb it as if it is toxic, and deadly, not as the Press release that is intended...
imho.
Who has selectively analyzed the DFDR to exclude the excursions present prior to a/p loss were due turbulence, and not the autoflight reacting to bs data? If so, the PF's situation becomes a little more explicit? Yes or no, where is that in Boudain's/Bouilliard's text? Where is "Nine prior Unreliable SPEED events occurred in a cluster less than one year pre-event?" Does he present the record of PROBE problems? The poor record of compliance? The utter lack of training that would have made his comments moot? Hmmm........
lyman
"IMO that could prove if it was (initially) unintended"..... Thank you A33Zab.
Anyone else resent the attempt to be led around by the ear as an errant schoolboy, by those with an incredible financial investment in the outcome of this investigation?
"Internists know everything, and do nothing. Surgeons know nothing, and do everything. Pathologists know everything, and do everything, but too late."
William Nolen, MD
I am not sure your point. If it is to emphasize the lack of proper procedures, you have. Something is missing, and it is exquisitely salient. The speech is given after the passage of time. Without a deliberate attempt to frame his comments in the context of the pilots situation it is misleading, to say the least.
Naturally, I will claim it is deliberate. It is.
He uses terms not in existence at the time of the crash. His summary is selectively exclusive, and presumptuous. Human nature being what it is, virtually everyone reading his text will absorb it in ignorance of its subtle purpose.
There was discussion of Pitch and Altitude, and immediately. The determination of UAS was made after 447 was on the bottom, I propose the crew were unaware of it until seventeen seconds after its appearance, and longer than that after its actual start. This presently can not be discounted, and bias and passion do not count as evidence......
Everything that is officially released, including data favorable to the crew,
must be received with profound distaste, and without prior thought....Absorb it as if it is toxic, and deadly, not as the Press release that is intended...
imho.
Who has selectively analyzed the DFDR to exclude the excursions present prior to a/p loss were due turbulence, and not the autoflight reacting to bs data? If so, the PF's situation becomes a little more explicit? Yes or no, where is that in Boudain's/Bouilliard's text? Where is "Nine prior Unreliable SPEED events occurred in a cluster less than one year pre-event?" Does he present the record of PROBE problems? The poor record of compliance? The utter lack of training that would have made his comments moot? Hmmm........
lyman
"IMO that could prove if it was (initially) unintended"..... Thank you A33Zab.
Anyone else resent the attempt to be led around by the ear as an errant schoolboy, by those with an incredible financial investment in the outcome of this investigation?
"Internists know everything, and do nothing. Surgeons know nothing, and do everything. Pathologists know everything, and do everything, but too late."
William Nolen, MD
Last edited by Lyman; 1st Jun 2012 at 16:10.
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My volatile and impatient bad, sir. My comments were directed at the propaganda nature of the text, and not directed at a motive of yours. Of everyone here, and I mean everyone, you are the most objective, imho.
lyman
A question. Your "Misreading a UAS procedure..." Wasn't UAS a term that happened along post wreck? That is what I meant by his bias in incorporating new data that the crew had no knowledge of. "Climb", as reported by Msr.B is a wild statement, and since his remarks were undoubtedly edited, proofread, and approved, isn't it a sample of the investigations bias, and even fecklessness?
rhetorical question, I wouldn'e have you compromse your position with an opinion
lyman
A question. Your "Misreading a UAS procedure..." Wasn't UAS a term that happened along post wreck? That is what I meant by his bias in incorporating new data that the crew had no knowledge of. "Climb", as reported by Msr.B is a wild statement, and since his remarks were undoubtedly edited, proofread, and approved, isn't it a sample of the investigations bias, and even fecklessness?
rhetorical question, I wouldn'e have you compromse your position with an opinion
Last edited by Lyman; 1st Jun 2012 at 16:34.
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Lyman,
One profession that specializes in hindsight bias is the Law profession, particularly tort law.
I believe you have more than passing familiarity with that profession.
I would like to also offer the observation that your posts are becoming more relevant. I only wish there were not so many of them.
One profession that specializes in hindsight bias is the Law profession, particularly tort law.
I believe you have more than passing familiarity with that profession.
I would like to also offer the observation that your posts are becoming more relevant. I only wish there were not so many of them.
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Mach
If I felt the discussion was more balanced, or at least objective (read anything by HazelNuts39) I would make an effort to reduce....
I also would like to hear more from you.
You climb, I descend, fair deal?
If I felt the discussion was more balanced, or at least objective (read anything by HazelNuts39) I would make an effort to reduce....
I also would like to hear more from you.
You climb, I descend, fair deal?
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Originally Posted by HN39
The point is that M. Bouillard is misreading the UAS procedure. He quotes a "Memory Item" that is not applicable at cruise altitude.
The way it is written, the MEMORY ITEMS are always applicable when the safe conduct of the flight is impacted.
In my book I don't know any situation when the safe conduct of a flight is NOT impacted. The altitude is far to be the only such factor.
Instead of :
- If the safe conduct of the flight is impacted : MEMORY ITEMS
the procedure should state :
- If below MSA : MEMORY ITEMS
- If or when above MSA : Level off for troubleshooting
Let's see if the BEA will mentioned how poorly the UAS procedure is still designed ... ?
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Hi,
We know by the most official source (the BEA itself) that is that the report will be released on July 5
It is not pretentious to say that the BEA currently holds the final report (it would not advance any precise date if he still had to conduct more investigations)
It raises the question .. why wait until the date of July 5th!
The BEA will publish the Final Report of the safety investigation on Thursday, 5 July, 2012 and at the same time will hold a press briefing.
It is not pretentious to say that the BEA currently holds the final report (it would not advance any precise date if he still had to conduct more investigations)
It raises the question .. why wait until the date of July 5th!
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If the BEA preferred, they would not release any report. The report has no upside for them, it is duty only, and cannot be shrugged...
Once released, it is become legend, there is no return, jcj......
There are ulcers proceeding in the bellies of the staff.
imo.
Once released, it is become legend, there is no return, jcj......
There are ulcers proceeding in the bellies of the staff.
imo.
alf5071h;
A very interesting critique, alf5071h, thank you for this. Having read and enjoyed your many observations here and elsewhere I know that there is a depth of knowledge and experience behind these comments.
I believe there is something more subtle than is being expressed in terms of categorizing "all that is said" only as hindsight. My question is, how do we proceed if all is merely hindsight and if not, what determines the difference? The paper you cite helps answer this question - so does Starbuck and Farjoun's later book, (2005), Organization Beyond the Limit.
However, I do argue that in the case challenged, (Fukushima), foresight was indeed in place but was set aside.
It is well understood, as demonstrated in the public record, that the risks of tsunami to the Fukushima Daichi installation were clearly stated long before the tsunami, (NYT, 2012). Further, it is clear that statements of clear risk and potential outcomes, (meltdown) were completely ignored by Tepco and others including the Japanese government. The risks were clearly delineated beforehand and the ensuing disaster as a result of a separate catastrophic natural event was entirely predictable and preventable. Hindsight bias is different than a recounting of the available record.
Well, in one sense no, never. We are not them, we were not there. Also, risky conclusions about how people behave can and do occur. As the paper you link to observes, even the CAIB attempted to avoid hindsight bias.
Foresight can arrive in a number of ways. The notions of possibilism are broached in Lee Clarke's two works, "Worst Cases" and "Mission Improbable". Possibilisitic thinking provides a context in which what is possible and not merely probable, may be discussed. In Fukushima, "what is possible" was dismissed as "improbable" and further consideration of "what is possible, (after a 9.0 earthquake and a tsunami had flooded the diesel generators)?" was deferred in favour of a probabalistic argument. Answering the question, "Why?" relies heavily on hindsight work and can be valid so long is not "after-casting" and that change based upon new knowledge results.
In this case foresight was not lacking, so was judgement flawed or was there "organizational structurally-induced inaction"; - were the actions of TEPCO closer to making management decisions rather than engineering safety decisions?Regardless, your observation is interesting and I think really worth discussing in depth as we near the next phase of the AF447 threads.
Old Carthusian, et al, How is this relevant to AF447? All that has been said or might be said about AF 447 or Fukushima, is in hindsight.
I believe there is something more subtle than is being expressed in terms of categorizing "all that is said" only as hindsight. My question is, how do we proceed if all is merely hindsight and if not, what determines the difference? The paper you cite helps answer this question - so does Starbuck and Farjoun's later book, (2005), Organization Beyond the Limit.
However, I do argue that in the case challenged, (Fukushima), foresight was indeed in place but was set aside.
It is well understood, as demonstrated in the public record, that the risks of tsunami to the Fukushima Daichi installation were clearly stated long before the tsunami, (NYT, 2012). Further, it is clear that statements of clear risk and potential outcomes, (meltdown) were completely ignored by Tepco and others including the Japanese government. The risks were clearly delineated beforehand and the ensuing disaster as a result of a separate catastrophic natural event was entirely predictable and preventable. Hindsight bias is different than a recounting of the available record.
Are we really able to understand the situation as these people did at the time of their assessment and decisions?
If we are, then we must carry equal responsibility for not acting to prevent such disasters. No, at best we might say that our judgement was flawed, or more accurately that we lacked foresight.
In this case foresight was not lacking, so was judgement flawed or was there "organizational structurally-induced inaction"; - were the actions of TEPCO closer to making management decisions rather than engineering safety decisions?Regardless, your observation is interesting and I think really worth discussing in depth as we near the next phase of the AF447 threads.
Last edited by PJ2; 1st Jun 2012 at 19:39.
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Shell Management:
From lyman : If the BEA preferred, they would not release any report. The report has no upside for them, it is DUTY only, and cannot be shrugged...
So thanks for the addendum....
PJ2, alf....
Foresight was in place prior 447...It is always in place. Given time, I could likely find the joker who warned Boeing about skin fatigue, and the COMET, and Alaskan's screw jack crimes.... Failures of epic proportion virtually never occur in a vacuum of data, or spontaneously.
QF 32? Want to talk to the man who warned Rolls about harmonics? Who was the guy on the floor, or the office, who saw the problem with the certification of the Thales? The THS potential for mischief? The STALLWARN issue? The over loud warnng of overspeed v SW?
damning evidence of failure is the enemy, in a pre "event" setting. It's in the superb link alf provided. STUPID STUPID STUPID. With a large dose of DENIAL, starry eyed paydays, and continued peer centered esteem.....It gets out of control, then all one can do is wait for the inevitable, and hope someone else is on duty when it happens, or one is parted the company, and for mutually beneficial reasons, anonymity will prevail....
If things go on long enough prior to the disaster, it will present that Mother Nature is at fault, with her weather, or robust thermal challenge of re-entry on a partially naked aircraft.....WRONG.
447 has all the elements of the longed for genesis of a catharsis to be welcomed.
When the chrome wears thin, one cannot merely paint...
From lyman : If the BEA preferred, they would not release any report. The report has no upside for them, it is DUTY only, and cannot be shrugged...
So thanks for the addendum....
PJ2, alf....
Foresight was in place prior 447...It is always in place. Given time, I could likely find the joker who warned Boeing about skin fatigue, and the COMET, and Alaskan's screw jack crimes.... Failures of epic proportion virtually never occur in a vacuum of data, or spontaneously.
QF 32? Want to talk to the man who warned Rolls about harmonics? Who was the guy on the floor, or the office, who saw the problem with the certification of the Thales? The THS potential for mischief? The STALLWARN issue? The over loud warnng of overspeed v SW?
damning evidence of failure is the enemy, in a pre "event" setting. It's in the superb link alf provided. STUPID STUPID STUPID. With a large dose of DENIAL, starry eyed paydays, and continued peer centered esteem.....It gets out of control, then all one can do is wait for the inevitable, and hope someone else is on duty when it happens, or one is parted the company, and for mutually beneficial reasons, anonymity will prevail....
If things go on long enough prior to the disaster, it will present that Mother Nature is at fault, with her weather, or robust thermal challenge of re-entry on a partially naked aircraft.....WRONG.
447 has all the elements of the longed for genesis of a catharsis to be welcomed.
When the chrome wears thin, one cannot merely paint...
Last edited by Lyman; 1st Jun 2012 at 21:52.
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Thank you mm43 for the link.
I don't know why, but after reading I recalled the statement of an airline boss - not in SAmerica or Africa, but of an flag carrier in the middle of Europe - "Passengers are not willing anymore to pay a little extra for safety....".
That was twenty years ago.
@HazelNut39
Well, as far as I did understand the procedure, above FL100 the memory items call for 5°/Climb thrust.
I found it strange, but as I never have flown a bus, I asked some friends current on the A330 and they concurred, although confirming, that they'd rather stay with the attitude/N1 which had been before the event.
May be you can explain what you ment. Here's a link to the procedure:
UAS.png - 4shared.com - photo sharing - download image
I don't know why, but after reading I recalled the statement of an airline boss - not in SAmerica or Africa, but of an flag carrier in the middle of Europe - "Passengers are not willing anymore to pay a little extra for safety....".
That was twenty years ago.
@HazelNut39
.......is misreading the UAS procedure. He quotes a "Memory Item" that is not applicable at cruise altitude.
I found it strange, but as I never have flown a bus, I asked some friends current on the A330 and they concurred, although confirming, that they'd rather stay with the attitude/N1 which had been before the event.
May be you can explain what you ment. Here's a link to the procedure:
UAS.png - 4shared.com - photo sharing - download image