Machinbird

Hi PJ2. I am assuming this statement was not directed at my previous posting but as a general caution to those who would analyze accidents. I have a copy of Mr. Dekker's field guide in my library. I have seen two accidents long ago that caused me to examine my thinking and I understand well how the cockpit view differs from the external view.

My conclusions with regard to AF447's crew's performance resulted from an analysis about what must happen for success, and then examining the record for evidence of these critical performance activities (and not finding them).

Dekker's new book " " is more likely to be highly relevant to the underlying causes of the AF447 accident. What has me highly concerned is that the same causes are very likely to be found active in other airlines to varying degrees due to the similar operating environment. Guess I know where I should use that Amazon gift certificate I received awhile ago .

My statement with regard to backdriving the sidestick should be interpreted as meaning that I believe it is technologically practical to do so based on my slightly outdated understanding of automation devices. It should not be interpreted as a recommendation. I would only suggest it if it was practical to lay a hand on the second stick and perceive the other side's inputs effectively by tactile means. That may require some research.

The PFD is highly cluttered already, and I too question the effectiveness of changing the color of portions of the display to signify important changes in operating mode. A stressed pilot is very likely to miss that type of cue.

ALF, It is a pleasure to have your input again on this thread.

That I think we already know. They were a part of the "Drift into Failure". Where the blame lands is for the courts to decide. However, blame is not relevant to accident investigations in most cases.

PJ2

Machinbird;

Re, "Hi PJ2. I am assuming this statement was not directed at my previous posting but as a general caution to those who would analyze accidents."

You assume correctly, and my apologies!...not directed your way at all, (as I know you know your stuff), but placed as part of the discussion I wished to have on the topic so that others might take up the conversation as well. I think it is a very timely discussion, given that the report is on its way. The quote I used is exactly as it appears in Dekker's book, including the "(you think)" phrase, (Ch 5/pg39) and it was my unfortunate oversight that did not clarify the quote.
Precisely.

There is no hindsight in examining the record of what is. Hindsight bias is an interpretive gesture, not an investigative act.

Your comments on the SS were taken as intended - as entries into the dialogue and not as recommendations or even suggestions.
Yes, we already know that it is possible for whatever reasons, to miss serious, emergency warnings designed to grab and focus attention. In my view I think this in itself is worth a full examination - why did this occur?

We know already that, first, comprehension through thorough training, and trust, which follows belief in the airplane and its systems and instrumentation, is paramount to safe flight. As many have said, we have here an accident like no other.

The record shows a lack of crew coordination and understanding of the airplane and of high altitude flight. Considering why, is an investigative act. I think the best example on record for highlighting this shift in thinking from thinking about how crews should behave to why they behaved the way they did, is still Diane Vaughn's book because she talks about her hindsight bias first and then shows how her persistent investigative work and open mind made such biases visible and provided the foundations for the shift in perception.
Indeed it is...also, great cartoon.
The following statement is a general observation and is NOT to be understood as referring specifically to any regulator or airline here. The statement carries no meaning other than what it says. That clear, I want to observe that we already know that too comfortable or cozy a relationship between regulator and private corporation is unhealthy for both, and also for the end-users of and in both organizations. It has occurred in the past and has resulted in incidents and accidents. The regulator must be free to enforce or support as necessary but to retain authority of standards. That was my initial reaction to SMS and as far as I'm concerned the jury is still out on the self-regulation of airline safety...another thread entirely.

CONF iture

No other tool that fully visible control columns can better enhance crew coordination - It is all about naturally sharing first hand information - A crew needs sharing, not hiding.

HazelNuts39

In the case of AF447, I believe a distinction should be made between phases 2 and 3. After the airplane stalled, seeing the control pulled to the back stop with the nose up might have helped to focus the PNF's awareness (and even more that of the captain) on the problem that the airplane was stalled. IMHO in phase 2 knowing the movements of the longitudinal control would not have added anything to the PNF's understanding of what was happening.

Lyman

from PJ2, quoting Machinbird

Quote:
My conclusions with regard to AF447's crew's performance resulted from an analysis about what must happen for success, and then examining the record for evidence of these critical performance activities (and not finding them).


from PJ2: "Precisely"

agreed.... That sustains a reasonable interpretation of a common metric, to wit:

"What did they know, and when did they know it." Which is a presumption requiring evidence to support, save for some linkage with actual commentary from the pilots....

To fine tune, "What was displayed, available; and what actions can be associated with its acquisition, comprehension, and 'action taken'.

So I will go out on a vulnerable scout, not all three pilots were untrained in probblematic high altitude flight, if we entertain that the two not "inputting" honestly were prevented due to poor design from sussing the control inputs of the PF.

alf, a question? Subject to humor, is hindsight bias a conclusion in itself subject to bias on the part of the judge?

The foresight discussion: "What did they know, and when did they know it"? Is susceptible to unprofessional critique, but I expect many in the Public will have all the bases covered.

I submit that this investigation has the potential, due new technology, to include widespread exposure. That will be good, and it will be bad...

Columbia, and Challenger before it, laid the groundwork for widespread exposure of the stupid things that are done by those previously protected by the culture from disclosure.

We will have to see how everyone reacts. The balance sheet will be written through time, but for me, the worn out buddy sytem and the conspiratorial secrecy that endangers the lives of the public is about to be tested, and there will be many things that are distasteful to know. The good, I believe, will far outweigh the dying rattle of a culture that may be held responsible for needless death, and that by greed.

HazelNuts39

Lyman

PJ2 says that neutral stick is easy to place, in the mind, by feel.... I believe.

So.... 1) The PF does not know where neutral is, or, 2) he does not know the NOSE position, or, 3) he thinks that minor corrections are needed with the stick back of neutral, similarly, when it is forward of neutral.

Would a Bus driver take the time to interpret for us the stick placements that killed them? Is it reasonable to comment on a partner's use of the Stick, or is it too 'personal'?

Another question that I think has not been addressed: Why is the pilot so stick busy? The aircraft is very large, very gentle in responses, and he looks like he flies a helicopter in a windstorm.....

CONF iture

At the very start of phase 2, the stick is already between neutral and 3/4 back. From my personal experience, I just cannot remember any control column 3/4 back at FL350, except maybe for an approach to STALL simulation ...
To witness such movement is simply shocking.

Machinbird

HN39 an excellent presentation of how the AF447 crew lost all their energy before the stall. Not as a concentrated pull up, but as an additive process with a nose up bias.

Another indication of a FUBAR scan.

HazelNuts39

Machinbird;

Thanks, I was having some trepidations about posting.

Lyman

Machinbird

"but as an additive process..." Could I ask for more? By additive, do you mean he piles on NU on NU? Increasing, without regard to result? You don't mean added to any process of a/c, eg THS? Or other action of which he was unaware?

Would you hazard a possible reason?

I ask because I find it impossible, given the evidence, that any second Pilot would allow the PF to eat paste whilst the a/c climbed as it did, according to the released evidence....

Consider this rhetorical if you like.

I think this "additive process" is in here somewhere.

OK465

With momentary audio stall warnings at 2:10:10 & 2:10:13, that graph itself would 'sell' me on an 'intrusive' PFD "PLI" for Alternate & Direct Law.

grity

a brocken rod-spring in the SS was and is seldom, but not impossible to lose the neutral point

PJ2

HN39;

Agree with Machinbird's comments. Thank you for posting this.

The graph shows clearly, the "time-spent-in-NU-territory" of the control input, and the resultant pitch trend.

PJ2

Lyman;
How do we know beforehand, that a culture is a buddy system and not an honest system? What are the metrics, beforehand? When do we know that people are "being protected" vice doing their job? How is "conspiratorial secrecy" recognized from "proprietary information" which, in a competitve political economy, is the lifeblood of all organizations? How do we parse and subsequently judge action in different discourses, the most well-known example being the "discussion" between Morton-Thiokol engineers (engineering discourse) and NASA managers at Houston (management/political/economic discourse), regarding the Challenger launch decision. Are the discourses "translatable" into a common language or do we have power politics as the arbiter?

A33Zab

implausible with dual cartridges:

PJ2

HN39, okay, thanks very much for the correction and the information. We let go of the stick in the sim exercise but that was in phase 1.

Lyman

PJ2.

How de we know beforehand? We don't, and that is the plan. Unless the domain is so witless or uncaring, no care is taken to protect eachother.

Oversight, Investigation, Audit, Inventory. These are costly, and so at the very least, profit deters their implementation. I was involved in an ad hoc investigation of seemingly above board process, the mission and its ennablers were clear to see. The laziness with which the chain of incompetence and criminality was covered up was breathtaking.

In aviation, the burden is borne by the common man, through taxes, and the product is consistent with most ventures assigned to the public 'servant'.

Government work.... "You want me to go the Moon aboard a device built by the lowest bidder?"

I have great respect for the FAA, EASA, and BEA, though that may raise an eyebrow or two. By and large, these are competent, and professional organizations. Asx they are public, Politics rears its drooling jaws, and leadership is awarded to whomever purchased more lunches or green fees for the Appointing wonk....

By and large, most of the sheer stupidity and underhandedness is found out, but generally because someone left the lights on....

The larger the consolidated process, the more power, and the more chance for hiding the truth.

Converesely, the smallest organizations tend to be the more corrupt, the consenting few make up the majority of the workforce, and so are well disposed to self protection.

Fukushima is a beacon and clarion. I see ample room for this accident (447) to accomplish some dark corner illumination, you?

Thanks for the action,

A33Zab: Yes, the Stick was fine, I personally am broaching the topic of feel, and PJ2 says Neutral is easy to suss.... So.. He establishes a climb as neutral, and builds and builds....Que paso?

PJ2... "Neutral". Someone needs to at least offer a possibility why PF chose to climb, and appeared not once to be satisfied.....With ADI, and a nosy PNF?

Duff ADI? not the first time, if at all.....What was PNF using then ISIS? Why was PF unaware, demonstrably, of his PITCH, or altitude? And since the climb was NEVER (assimilated) here is the cause, the precise cause. Now we hone in on the possibilities...... If someone, a neutral, is allowed to hear the CVR from 20 seconds either side of 2:10:05, I'll say fine. Complete, tested, and authenticated.

Come on Lyman, BEA playing games?

PJ2

Lyman;
I am counting on the BEA Human Factors Group for this. Many here have posited serious and plausible theories to account for the sustained NU input. Early on, the Airborne Express DC8 accident was introduced as a possible explanation - the natural tendency to pull back if going down; - the DC8's control column was held in the full-NU position all the way to impact, as was the case with the Northwest Airlines B727 accident. The memorized UAS drill has been discussed, with sub-theories attending to a general inexperience in high-altitude manual handling of transport aircraft throughout the industry possibly pointing to a correct but over-controlled input by the PF and tolerance by the PNF while the PF settled the response down. Inadvertent, unintended NU input while responding to the right roll has been discussed.
In examining the U.S. political economy and events which led to October 2008 and the numerous boom-bust cycles from the Nineteenth Century on, yes, I agree with all your views. Dekker and others have written about "what's common" between aviation, medical and economic "accidents" and I think there is fertile ground for decades of research from which ad-hoc societal change will emerge. The masses will eat cake for only so long, so to speak, but, except for very specific areas of concurrence when it comes to why organizational accidents occur, we are way off topic. I re-emphasize that I think Vaughn's book is the reference work for highlighting the shift from assessements of amoral calculation to the normalization of deviance, which, I believe, is far more prevalent as an operative factor in organizational behaviours, at least in high-risk enterprises, than the former.

A33Zab

Ok, and that's exactly reason to investigate the seat/armrest position: