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AF 447 Thread No. 8

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Old 3rd Jun 2012, 00:32
  #1061 (permalink)  
 
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I do apologize for leaving out a few words. I know that sounds amazing, but,

Unbelted: to include, 'improperly', and 'loosely'.

Neutral stick. A poor attempt at irony. He had no chance to pause, he was very busy with ROLL. My subtlety or lack thereof had to do with him attempting to acclimate to a stick that had gone schizophrenic, touchy in Roll, and by comparison lethargic in PITCH. To accomodate and thereby coordinate control inputs must have been annoying, if not downright dangerous.....

Imho
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Old 3rd Jun 2012, 02:55
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the Final has been translated into Portuguese, and shipped to Brasil. Parts have leaked, I am on the first page, so far nothing new. It can be found on another wewbsite....

Last edited by Lyman; 3rd Jun 2012 at 02:56.
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Old 3rd Jun 2012, 03:18
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Cool

Hi,

Oglobo
Voo AF 447: relatório aponta falha humana - O Globo
G1 - Brasil recebe relatório final sobre a queda do AF 447; saiba detalhes - notícias em Acidente do Voo AF 447
Research data confronted the black boxes with actions and answers the cabin of the aircraft and point to the design of the cockpit, the operator of the Airbus and the lack of proper training are among the main conditions for the pilots did not understand why the plane went down
Ite Missa Est

Last edited by jcjeant; 3rd Jun 2012 at 03:25.
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Old 3rd Jun 2012, 11:06
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Lyman
If we do indeed assume that the PF was 'unbelted' a simple statement to his colleague - 'You have the controls' would be enough. He could then deal with whatever issues he had and retake control at a later stage. Once again CRM would seem to be lacking but even so there is no evidence of this set of circumstances.
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Old 3rd Jun 2012, 12:19
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Lyman
I am on the first page, so far nothing new.
What could there be any new ?
Comments on human factors .. results of the special investigation panel of BEA?
This can be as imprecise literature
When a person (eg a criminal) is reviewed by a group of psychiatrists .. some will declared it insane and the others just said he is normal
I don't wait many interesting news in the final report ... all was already in the interim report N°3
Maybe few new recommendations ....

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Old 3rd Jun 2012, 13:00
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OC You missed my addend : Unbelted: to include, 'improperly', and 'loosely'.


Jcj. I don't wait many interesting news in the final report ... all was already in the interim report N°3

I disagree. There has been time to research thousands of pieces of evidence, interviews, and to experiment with new experts, and engage new disciplines. I think it will be quite something. I also think we will see some excellent results.

Thanks

Last edited by Lyman; 3rd Jun 2012 at 13:06.
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Old 3rd Jun 2012, 13:34
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Originally Posted by Lyman
There has been time to research thousands of pieces of evidence, interviews, and to experiment with new experts, and engage new disciplines.
No doubt that has been done. But it is possible that all that effort has not produced new facts or insights, other than dotting a few i's and crossing some t's. IMHO the brasilian newspaper article could have been written from IR#3.
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Old 3rd Jun 2012, 13:49
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Or perhaps from PPRuNe.
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Old 3rd Jun 2012, 17:27
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Text of final report leaked in Brazil

"A disposiçăo de informaçőes no painel e o design da cabine da aeronave foram fatores que contribuíram para dificultar que a tripulaçăo identificasse a açăo errada do copiloto menos experiente "
"The display of informations at the panel and the design of the aircraft's cockpit were factors that contributed in hindering the crew to identify the wrong actions of the less experienced copilot"

If this is really written in the final report, then one could read between the lines, that those who criticized the SS layout sound more credible now, even in the eyes of BEA.
Just how I see it.

@PJ2

I definitely share your view on applying the UAS procedure at high altitudes. Just wanted to show the abnormal procedure used at time of the accident and that Mr. Bouillard obviousely referred to it.

IMHO let alone the lacking airmanship and CRM, I find it very strange that after some 30 incidents with those pitots there had been no real reaction in creating procedures a bit more refined and training of high altitude loss of airspeed.
As to lacking airmanship, in computerized planes, with training reduced to the absolute minimum (because the plane will take care of the limits, dosn't it?..) how could young pilots gain this airmanship when they touch the SS only a couple of minutes every month and flew only a minimum on classic aircraft before taking the right frontseat of a bus?
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Old 3rd Jun 2012, 17:48
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It is not particularly world shattering for the BEA to highlight the stick placement, if indeed, that is what they did. It is obvious without their affirmation. Hamburg again comes to mind.

As designed, and built, the SS stands on its own, there is not wiggle room for the decision. The team missed nothing, and assented to the layout warts and all.

For the third time I will point out the possibilities for ultimate single pilot carriage is obvious. You think the designers would leap without some sort of raison d'ętre for such a novel rig?

Should there be proof of mistake, and unplanned for possibility, the SS is single pilot in action, de Facto. Anyways.....

Once the ship lost her a/p, and her speeds reads, in the additional absence of CRM, she was functionally single pilot.......

I reject any "but a yoke system...." etc. In the Bus cockpit, the deck is stacked from the gitgo..... "I have been pulling up for some time...." No problem. QUE?

A Fix? Perhaps fisheye blind spot mirrors..... Next to the new Video Recording System?

Last edited by Lyman; 3rd Jun 2012 at 19:03.
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Old 3rd Jun 2012, 18:20
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Hi Maching Bird,

Originally Posted by Machinbird
My French is terrible, but what does the short sentence at the top of the procedure posted by Flyinheavy say? It seems to indicate that if the conduct of the flight is endangered then.........
If that is anywhere close to the meaning, then at cruise FL, the procedure is NA(Not Applicable)
No problem with your French, your traduction is perfect... Better than my English...

But there is no "N/A" in the French UAS procedure, so don't worry !

The original French text in BEA#3 p.61 is :

SI CONDUITE DU VOL AFFECTEE DANGEREUSEMENT le CDB annonce "IAS DOUTEUSE" - effectuer les actions immédiates suivantes :
.
.
.
The three problems I see with that text are :
1. The CDB (the Captain, not BONIN) has to decide and announce
2. If the CDB judges that the flight is not endangered, nobody advertises "IAS DOUTEUSE" (UAS)
3. Is altitude cause of possible endangering associated with UAS ?


@jcjeant
Thank you for Oglobo ref : The Brazilian are always the first in the AF447 story !

Last edited by roulishollandais; 5th Jun 2012 at 15:48. Reason: spelling
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Old 3rd Jun 2012, 18:32
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@Flyinheavy:
If this is really written in the final report, then one could read between the lines, that those who criticized the SS layout sound more credible now, even in the eyes of BEA.
Indeed. IMHO, that would be great. The key words are your beginning ones-- for information of this type, source is everything. This is an unknown source with absolutely no bonafides. We really don't know what the source is or where it came from. Tempting as it may be to draw conclusions, I'm taking this "report" with less than a grain of salt.

Let's take a month off and wait. (For Thread #s 9, 10, 11, etc.)
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Old 3rd Jun 2012, 19:06
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Orgnfrek....

Less than a grain? Here, my shaker, you'll need more.
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Old 3rd Jun 2012, 19:16
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Snoop Thank you to non French PPRuNers

O Globo shows once more it is one of the greatest media in the world. They already were the first to publish the Acars. With AF447 we have to thank and congratulate our Brazilian friends for showing a modern conception of aviation, and in sharing air safety informations.

The only better media, were Ppruner, indeed !

As a French retired pilot I am sure that you all, not French, have helped seriously France to overcome pressures over French Aerospace.

Thank you !

Last edited by roulishollandais; 5th Jun 2012 at 15:43. Reason: spelling
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Old 3rd Jun 2012, 19:40
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A ggogle translation of this website:

Brasilian military


Brazil receives final report on the fall of 447

France officially release the document on July 5. Tragedy that killed 228 people completed three years on Friday

Tahiane Stochero

The pilots of flight 447 did not understand the time the plane lost support after a procedure wrong copilot's newest and this led to the crash, which killed 228 people on 1 June 2009. In the final seconds, they tried to prevent the accident, but the aircraft was already so low speed reversing the decline of the Airbus A-330 Air France - which had departed from Rio de Janeiro and went towards Paris - the Atlantic Ocean, three years ago, it was virtually impossible . The provision of information on the panel and the design of the cabin of the aircraft were factors that contributed to hinder the crew identified the wrong action of the less experienced co-pilot - who was with the commands - and also that the plane was falling because he has lost support.



These records included in the final report that the BEA (Bureau of Investigations and Analysis, in charge of the investigation) says it will unveil on July 5. The document has been received from Brazil, USA and Germany to the final considerations, as found the G1 . According to international law, the Chicago Convention, countries have 60 days to forward its position. BEA can not change the text based on the weights made, but they should be included in the final report.

Research data confronted the black boxes with actions and answers the cabin of the aircraft and point to the design of the cab, the operator of the Airbus and the lack of proper training are among the main conditions for the pilots did not understand why the plane went down. Three other preliminary reports were produced by the French organ. The latter already had the information from black boxes and copilot reported that the youngest was in command of the aircraft. The commander had left the post to go to sleep just before entering into a storm, without a clear division of tasks between the co-pilot.

When passing the storm, low external temperature sensors pitot freeze and block the speed measurement. Without accurate information, the Airbus out of the autopilot. The copilot assumes newest commands, and an attitude that does not know how to explain, raises the nose of the aircraft, causing the stall alarm (loss of lift) double tap. With the procedure of climb, the plane loses speed even more and really start to lose support. The stall horn playing more than 70 times - some for nearly a minute uninterrupted. copilot The youngest, who is in command, it keeps climbing action, while the corrreto would play the nose of the plane down speed and retrieving support and prevent the accident. None of the pilots had received training in case of loss of support of Airbus in high altitude and speed without reliable information. The more experienced co-pilot comes to giving, at times, the order for his colleague to take the right attitude, but is not aware of the mistaken action of his companion, and this was hampered by a lack of information about the real situation in stall Airbus panel.

When called upon by more experienced co-pilot, the captain returns to the cabin about 3 minutes after the fall of the autopilot. He does not understand what occurs and does not take any action. Less than 1 minute later, the Airbus collides with water.
In no time, passengers were given notice of the problem. All 228 aboard died in the tragedy. Only 153 bodies were identified after a search.

Control System

BEA created a working group to try to understand the actions of the crew cabin and psychological factors - such as pressure, stress, work overload, or prior knowledge - interfered with the tragedy. But what the pilots thought at the time it is impossible to determine. One of the hypotheses are the changes made ​​during the flight control modes of "fly-by-wire" Airbus.
When the autopilot disconnected, the computer becomes "normal law" (so that it protects against the plane movements and avoid the wrong stall) for "alternate law" (with few protections on the actions of the pilot). There are two forms of "alternate law" - one with and one without protection stall.
When pitots computer froze and began to receive information from disparate speeds, the A330 went into "alternate law" unprotected stall. It is possible that the rookie driver did not understand some of the restrictions of the system and had never flown in this mode.
Check out 11 factors that led to the accident on 447 on 1 June 2009:

Flight control

Flight 447 departed from Rio International Airport, in Rio de Janeiro on the night of May 31. When flying over the region monitored by Cindacta of Recife, the controller makes contact with the flight crew believed to be another flight, also from Air France, which had left St. Paul at the same time. The commander realizes the error and warn.
Minutes later, the controller is a new radio frequency that the crew should use to contact with Senegal (the next area of radar coverage). The commander repeats the numbers (the action is called collation), but a return of 12 digits. The controller in Recife do not realize the error. Later, a Brazilian driver attempts to contact - unsuccessfully - three times with 447. The region is not covered by radar, the aircraft was not connected to a satellite system that would allow sending data.

Location and rescue

Air France was no delay in reporting the disappearance of the flight and to start the search. It also controls the airspace of Brazil and Senegal took to notice the disappearance of the Airbus A330.
Aircraft and ships from France, USA and Brazil have been moved to the area only during the day. According to the black box, the drop occurred at 2h14min28s GMT (23h14 in GMT). The first wreckage and bodies begin to be found almost a week later.

Storm (weather)

When the aircraft goes into the storm, the clouds a bit concerned about the pilots. They comment on the meteorological factors and had already faced similar situations and worse. The turbulence level increases slightly, but that's not enough to scare. The storm may have acted as a psychological factor, such as increased stress. And there was a failure in the analysis of weather conditions. The crew could have changed the route and diverted the storm, as other aircraft that have made ​​the same trip that night.

Pitot probes

In the passage above the storm, the outdoor temperature drops too and there is ice buildup on pitot probes, which ceased to have correct information about the speed. The system began to receive information three different speed, and the autopilot disconnected. Air France said at the time he was in the process of exchange of other probes that resist up to - 50 ° C. The manufacturer and the agencies that regulate civil aviation in Europe and Brazil could have required that the model only fly at high altitudes with pitot greater resistance.

Lack of understanding

Pilots do not understand what is happening, even with the stall horn playing 75 times. They also do not understand what information was correct. None of the pilots identified formalmanente stall the situation and none of the pilots mentions aloud the stall, which is standard procedure. The passengers received no warning.

Error procedure

When the autopilot disconnects, the youngest rider began to put the plane's nose upward, causing a stall situation. No one knows the reason which led him to make such a decision. The correct action would be to play the Airbus nose down to gain speed and recover support.
The BEA noted that "in less than a minute after turning off the autopilot, the plane leaves its field of flight as a result of the actions of pilot manual, mainly to raise the nose."

Management cabin

The failure of management control cabin (CRM as the acronym is known in the aviation community) is considered an important factor. The commander was rest and gave his place to the most novice copilot, while recommendations and clear division of tasks between the co-pilot. The less experienced co-pilot (Pierre-Cedric Bonin, 32, and 2936 hours of flight) takes over.
The more experienced co-pilot (David Robert, 37, and 6547 hours of flight) take long to realize that his partner was taking the wrong attitude. Just got in the last seconds before the Airbus colliding with water.
The preliminary report has already pointed out the need for a system with greater autonomy for the post of co-pilot, allowing a greater division of labor in the control of Airbus.
Automatism
There is no way of knowing what caused the less experienced co-pilot to commit the mistake and why the other two pilots did not understand the stall horn. One possibility is the control system of the Airbus (fly-by-wire). Pilots could be believing they were in a control mode - where the aircraft went in after the loss of information and the fall of the autopilot - he had protection for stall (loss of support). not known whether the pilots ignored the stall horn because they believed it was a spurious signal. Another issue is the lack of a visual indicator to pilots during the fall, the actual level of stall (the factor is called the incidence and activates the alarm loss of support).

Cabin Design

The position and design of the cabin may have impaired the most experienced driver to miss the wrong attitude of the beginner. The "control stick" (or "side stick" device similar to the video game controller used to send orders to the computer) is positioned below the side window next to the seat of each pilot. This position could disrupt one of the pilots to see the orders that the other is going to the aircraft. This observation, however, is relativized because the command appears on the control panel in front of the pilots when the order is given. Despite the low speed and the aircraft no longer flying, pilots, cabin, did not realize, nor had the view that this occurred.

Training

The pilots had not received training to deal with loss of control at high altitude and not on reversing situations stall at high altitude.

Stall

The loss of lift of the aircraft is the cause of decrease of A-330. The plane estolou and remained in this situation because of the wrong procedure of the pilot, according to BEA.
The final report will recommend improvements in the alarm system and the manner in which pilots can view directly on the panel the incidence of slope and position of the aircraft stall.

The G1 searched Air France, but until the publication of this article received no return. In a statement to the G1 , Airbus said that "the authorities investigating the accident did not identify any problems related to aircraft" and that "to date, no recommendations "related to the model. "The report of the BEA has not yet been published, so any mention in the press is mere speculation," says the manufacturer. About the functionality of the cabin, Airbus says it "has been used for decades and was designed with the drivers of companies Airlines and industry officials. " The construction adds that "the system of cockpit Airbus Fly-by-Wire is in operation since 1988 and already counts 143 million flight hours and 65 million flights today."

Last edited by RetiredF4; 3rd Jun 2012 at 19:43.
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Old 3rd Jun 2012, 20:05
  #1076 (permalink)  
 
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Backdrive of SS and Human factors.

Should it be deemed necessary, it is very likely that an electronic backdrive of a not in use sidestick could be done within the space available. Of course, the interpreting software would need significant "adjustment" to the new circumstances.

From the dialog reported in interim report 3, it is clear to me that neither PF or PM's scans ever came up to speed, but instead got stuck staring at just a few parameters. The process of integrating the data into a full picture never actually happened.

IMHO, That is the root cause of this accident. Whatever PF was attempting to do with the aircraft, he did not integrate what effects his control inputs were having on his mental picture of what the aircraft was doing.

The only cure I know of for such a scan problem is hand flying---Lots of it! You could do it in the sim, but the natural fallout would be a much larger installed base of simulators to support the program.

Perhaps it is possible to develop a computer application that could be positioned in pilot briefing areas that would provide this refresher training, or within one's own laptop for practice as you felt the need.

However, I still look at all that cruise flying that is presently being given to Otto as the best, most realistic, cheapest, potential vehicle for training.

I am a firm believer in overtraining in such a critical skill as scan. For example, USN's theory on carrier landing practice was to do the first familiarization bounce pattern during the day, and then move all the remainder of the bounce periods into night work. For your edification, the night bounce was flown identically to the day pattern with a 600 foot downwind altitude. The bounce field was in an area with little ground lighting (until the housing moved in much later). This was a combination of instrument scan and visual scan to fly the pattern (which is about as demanding and realistic as you can get.) Each pass was graded by a qualified Landing Signals Officer, so there was no playing around. This instilled in all of us a virtually unbreakable scan.

It remains to be seen whether AF447 is indeed the canary in the coal mine for more LOC accidents of this type.

Note: I am using a definition of scan which includes developing a mental picture of what the aircraft is doing. I believe others are using this term as the process of just reading the indications on the instrument panel.
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Old 3rd Jun 2012, 20:08
  #1077 (permalink)  
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When called upon by more experienced co-pilot, the captain returns to the cabin about 3 minutes after the fall of the autopilot. He does not understand what occurs and does not take any action. Less than 1 minute later, the Airbus collides with water.
Interim Report N°3:

AP disconnect: 2:10:05
Captain returns: 2:11:43 (roughly 1 and a half minutes)
End of recording: 2:14:28 (little less than 3 minutes)
 
Old 3rd Jun 2012, 21:46
  #1078 (permalink)  
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Machinbird;

If they're going to recommend an actual change in the SS installation, ( as opposed to merely commenting on it...the word "rationalized" is in the Google translation which I take to mean "mitigated" which I again take to mean "even though there may be a visibility matter which may have contributed to a loss of control, no recommendation to alter the design is made", or something like that), then, along with any backdrive solution, a display of the stick position is going to have to be available because it is not at all easy to judge how much stick deflection is being applied by the other pilot purely by looking at it. This is because, first, the stick movement is small compared to a CC, and second, from the other seat, it is difficult to judge where "neutral" is. Placing a neutral marker near the SS for either the fore-aft or sideways movements of the stick to be accurately judged is difficult given the placement of the stick and it's surrounding structure, and parallax would be an issue.

The same display that we see at takeoff is an obvious solution. Presentation would be slightly different than the takeoff one; (the symbol is not visible on landing). The iron-cross could be placed in a circle. It's position indicates stick position. Concentric markers can indicate degrees and that can even be displayed digitally in a small box which is "attached" to the SS symbol. That's one way to display it on the PFD.

Obviously it wouldn't be there during autoflight and choosing when and how to make the SS symbol available and where, during manual flight, would require thought about of the importance and therefore the attention-getting priority of the information. (I always found the amber Alternate Law symbols vague and not at all obvious, but then at the time, purely out of decades of habit we flew the airplane as though there were no protections. And we "looked through" the FDs because they were rudimentary and the raw horizon data was "real". The subtle psychological shift that has occurred in the "children of the computer age" who know nothing of airplanes before the kinds of autoflight solutions we have today perhaps requires that a clearer indication be available to the crew that the airplane is in Alternate Law even though it is annunciated on the ECAM and is a checklist item.)

There is an obvious drawback to any new display of information: It must compete for the pilots' attention and possible action and it must be standardized/trained/checked.

However, in this debate regarding back-driven sticks and more information regarding SS position, I think the solutions are not in this direction but in a philosophical shift in approaches to training. In some quarters, it is indeed occurring already as enlightened managers and perhaps the occasional CEO who read a lot more than balance sheets are beginning to comprehend that automation has its place and it is not as "the third pilot".

This shift in training priorities and focus is not something that individual pilots can do by themselves. This is not a home-study-course problem. This is a performance problem, and must be worked into recurrent simulator sessions, check flights and must have standards by which success or "drift into failure" can be measured.

The self-fulfilling actions of airlines which tighten hand-flying restrictions after an incident must be examined and changed, especially for long-haul transport crews. Yet airlines are extremely reluctant to "waste all that automation they paid for" and implore crews to keep the autoflight engaged until late in the approach, taking over about thirty seconds before touchdown. Because of RNP restrictions and complex SIDs and STAR Profiles, hand-flying is not only discouraged but in some cases prohibited by airline policies given the speed and altitude accuracies demanded by these navigation procedures.

AF has run a FOQA/FDA/FDM Program for decades. This kind of program can pinpoint very easily and quickly, degradations in such standards. One sees this in a number of ways, but the character and nature of the approach and landing phase is the best area to examine.

Sidney Dekker has just put out another great book entitled, "
Drift into Failure Drift into Failure
". "Drift towards failure" is discussed in the Woods article to which alf5071h referred a few pages ago when referring to hindsight and hindsight bias. Dekker discusses hindsight and the phenomenon of hindsight bias. He discusses the "normalization of deviance", a notion and term which Vaughn created in her superb sociological study, "
The Challenger Launch Decision - Risky Technology, Culture, and Deviance at NASA The Challenger Launch Decision - Risky Technology, Culture, and Deviance at NASA
", (1996, University of Chicago). (Another superb work was hinted at by alf5071h in the same post, by Starbuck and Farjoun, (
Organization at the Limit Organization at the Limit
, 2005, Blackwell, in which the Woods article now appears).

Dekker also contributes a succinct understanding and measure, by which the phenomenon of hindsight bias is made visible in our thinking and discussions: He writes in "
The Field Guide to Understanding Human Error The Field Guide to Understanding Human Error
", (2006, Ashgate), "What (you think) should have happened cannot explain people's behaviour."

How then, will the BEA Report address the issues made clear to us in the data and three years of discussion and examination?

Last edited by PJ2; 3rd Jun 2012 at 22:51.
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Old 4th Jun 2012, 00:23
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PJ2, Machinbird

It will be of interest to note whether the BEA's Human Factors Group report is included in the Final as an Appendix in its entirety, or if the BEA chooses to selectively use its contents as a means of 'backing' the recommendations it (BEA) presents.

The issue of back-driving the SS will be contentious as demonstrated by content in these threads. So the SS position on the PFDs when the A/P disconnects seems the only option, though it will add to the 'scan clutter' and has received a number of vetoes in these threads.

All the other issues, including CRM, training and handling skills have been dissected in great detail here, and as far as I'm concerned the professional abilities of those involved in this accident leave a lot to be desired. Where the blame will be "sheeted home" will primarily be with the airline, though one has to ask, "What part did the Regulator have in this lackadaisical environment ?"
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Old 4th Jun 2012, 02:39
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Hindsight

For those who have yet to believe … and might be able to learn … if only …

With apologies to Peter Nicholson.
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