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AF 447 Thread No. 8

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Old 11th Jun 2012, 16:03
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Lyman, TTex600;
Quote:
Originally Posted by Lyman
*
Quote:
We do not have any evidence that the crew actually followed any procedure to identify what the cause of the initial situation was.
We also have not seen a procedure to follow.

Good point. The rote is trained, the thinking is not.
Well, we know what documents are available that deal with the UAS and ADR abnormals. We don't yet know what's trained. I referenced some documents in a post to Flyinheavy, on June 1: http://www.pprune.org/tech-log/48235...ml#post7222304 .

So we know at least, that the information to deal with the UAS event and/or failed ADRs was available and provided very specific guidance on how to do the memory items, the checklist items and what the thinking was behind the 2006 update. The thinking is clear, but again we don't know what the training actually was with reference to these documents. Also, these documents may not be available to all operators. They are not "required" for action in the same sense as, say, an AD.

O.C.

I thought about your response and agreed with it because to pilots it makes sense..."If not the UAS drill/checklist specifically, why not the standard SOPs at least?"

To be clinically accurate with reference to alf5071h's point concerning hindsight bias, we still have hints of the statement, "Why didn't they stick to SOPs?" One way to examine the question is, "How far back do we go before making up our minds as to what happened?" Can we ever make up our minds and say?


The other side of this same question is here, in PPRuNe: We have spent nine threads and three years and are still unable to say why, and we remain unable to say why the aircraft was pitched up and, more importantly, why it was held there when all of us who fly transports know that the airplane is going to run out of energy with the pitch attitudes recorded in the data. We know this to be true and expect that others who do this work would know too. How do we sort that out so that realistic, preventative action may take place? Or is hindsight bias increasingly serving the courts?

Acknowledging the phenomenon of hindsight bias still permits learning and change from "mistakes" but not because of the assumptions we may about such (assumed) "mistakes" or pilot behaviour which we can read in the tiny little bits of data we have from the recorders. How we learn is perhaps captured in the statement we're all familiar with: "The crew did not wake up that morning intending to have an accident." We might even extend this to organizational thinking.

From Dekker's, Drift Into Failure:

"The idea of the amoral calculator, of course, works only if we can prove that people knew, or could reasonably have known, that things were going to go wrong as a result of their decisions. Since the 1970's, we have 'proven' the time and again in accident inquiries (for which the public costs have risen sharply since the 1970's) and courts of law. Our conclusions are most often that bad or miscreant people made amoral trade-offs, that they didn't invest enough effort, or that they were negligent in their understanding of how their own system worked. Such findings not only instantiate, but keep reproducing the Newtonian-Cartesian logic that is so common-sense to us. We hardly see it anymore, it has become almost transparent. Our activities in the wake of failure are steeped in the language of this worldview: Accident inquiries are supposed to return probable 'causes.' The people who participate in them are expected by media and industry to explain themselves and their work in terms of broken parts (we have found what was wrong: here it is). Even so-called 'systemic' accident models serve as a vehicle to find broken parts, though higher upstream, away from the sharp end (deficient supervision, insufficient leadership). In courts, we argue that people could reasonably have foreseen harm, and that harm was indeed 'caused' by their action or omission. We couple assessments of the extent of negligence, or the depth of the moral depravity of people's decisions, to the size of the outcome. If the outcome was worse (more oil leakage, more dead bodies), then the actions that led up to it must have been really, really bad. The fine gets higher, the prison sentence longer.

t is not, of course, that applying this family of explanations leads to results that are simply false. That would be an unsustainable and useless position to take. If the worldview behind these explanations remains invisible to us, however, we will never be able to discover just how it influecnes our own rationalities. We will not be able to question it, nor our own assumptions. We might simply assume that this is the only to look at the world. And that is a severe restriction, a restriction that matters. Applying this worldview, after all, leads to particular results."

- Dekker, Sidney. Drift Into Failure, Surrey, Ashgate, 2011, p.5-6

Last edited by PJ2; 11th Jun 2012 at 16:18.
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Old 11th Jun 2012, 16:18
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PJ2 done wrote:
To be clinically accurate with reference to alf5071h's point concerning hindsight bias, we still have hints of the statement, "Why didn't they stick to SOPs?", when we have spent nine threads and three years unable to say why, and we remain unable to say why the aircraft was pitched up and, more importantly, why it was held there when all of us [emphasis mine] who fly transports know that the airplane is going to run out of energy with the pitch attitudes recorded in the data.
This puts me right back to the simplistic thinking (and sorry to snip the rest of your totally germane post), that there HAD to have been something wrong with the displays. It's the only answer that makes sense to me. Data has been withheld in the interim reports, as has been stated here many times.
Go ahead, shoot me down; I don't care; I can't fall very far from my armchair.
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Old 11th Jun 2012, 16:28
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Organfreak;

Regardingf what was on the PF's PFD/ND displays, it has been argued before, but inconclusively, like the argument that the PF was following the FDs. We just don't know and there is no data which tells us that this is what occurred.

What's more, once open, those kinds of doors swing both ways - as much as one may be totally convinced that one's notion is correct regarding what occurred and why, someone else may posit an entirely reasonable counterexample and there you are...mere theory, no fact, no conclusion or worse, dangerous conclusion(s).

We are not paralyzed; we are in a new "evidence space" which directs responses differently.
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Old 11th Jun 2012, 16:36
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Well PJ2, I fully realize there are no facts or evidence to support-- I'm indulging myself in a completely groundless speculation, just for once, because mindless certainty feels so much better than the unknown.
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Old 11th Jun 2012, 16:58
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Yes, it does, until it doesn't! ;-)

The notion of "amoral calculation" was used by Vaughn in her book on Challenger. She slowly shifted in her view that NASA engineers and managers intentionally placed the shuttle and the crew at risk due to production pressures and long-term cost-controls. She eventually concluded that the very opposite was occurring...that everyone thought that they were doing exactly the right thing.

I think we can take it that the PF thought the same thing. I am hoping that the BEA HF Group can do for the crew of AF447 and all those affected, the same thing that Vaughn did for the crew of Challenger.
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Old 11th Jun 2012, 17:24
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The hard data is in the ACARS...The crew were not privy. Neither were they privy to data supplied for the post mortem via the recorders. Unwinding a little bit of the conclusionary tone here, Organfreak has repositioned the discussion.

Unless and until the complete record is available, even the BEA report will need a salt shaker.

PJ2:

"....say why the aircraft was pitched up and, more importantly, why it was held there when all of us who fly transports know that the airplane is going to run out of energy with the pitch attitudes recorded in the data."

Without knowing the state of the displays, the rhetoric has the crew in the corner, perhaps forever. It remains to be seen that the conditions were benign re: recovery. By benign I mean framed so by those who would condemn......

Re: Vaughn/Challenger. I never thought the Challenger case due malevolence. The incident happened post launch, thus inviting hindsight bias from the outset.

What I do think, is that Staff made a decision that involved risk management, out of their job description, and without proper oversight. Doubt can save the poodle, or kill it....In the Challenger case, the structural process was abdicated/co-opted, by those who ignored the safeguards. Negligent? Of course....

It is chilling to think that these situations can crop up just as they did when we did not know "better".....
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Old 11th Jun 2012, 17:40
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Question Trim, a technical question.

When considering the differences between events, some of the initial climbs were with autopilot engaged, AF447 was not.
Is there any difference in the pitch trim rate between autopilot engaged and manual flight, between normal and alternate law, or between any of the previous options and that which might be seen with over-speed protection?
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Old 11th Jun 2012, 17:43
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Lyman,
Organfreak has repositioned the discussion.
Strictly by accident, I assure you. I doubt I have that power. Sorry if I was rude to you last week, even if you did deserve it.
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Old 11th Jun 2012, 17:49
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Safetypee, great handle!
It is my understanding, as discussed in thread #s Gazillion, that this particular flavor of ALT Law included full auto-pitch trim. Apparently, to catch you up, it did exactly as PF commanded, which was to wind-up to almost full nose-up. Doubtful if this helped. It has been opined by somebody here that there's no good reason for auto-trim in ALT2B, and probably added to the confusion.
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Old 11th Jun 2012, 19:30
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Organfreak, thanks. My line of thought is if there were to be a difference in trim rates, then the manual-flight trim-follow-up could result in a more extreme attitude (or lower trimmed airspeed) than for autopilot/autotrim for the same duration; where duration might be the satisfaction of a flight guidance (FD) command.

An alternative view of this might be any difference in the flight control pitch rate limit between manual and autoflight (or over speed pull-up); expecting that manual flight would enable higher pitch rates than for the autopilot.
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Old 11th Jun 2012, 19:39
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Hi

Answering here to A-FLOOR, from the thread "Humbling sim experience", in an effort not to hijack it for too long

Re: Overspeed and understanding of stall situation in AF447
Originally Posted by A-FLOOR
Have you read the CVR transcipt?
Yes I did, thank you. En français dans le texte, qui plus est.
1/ At one time, the PF though the aircraft was (too?) speedy ("J’ai l’impression qu’on a une vitesse de fou non qu’est-ce que vous en pensez ?") but the aircraft was not. As the overspeed protection listen to its sensor inputs, and not to the PF mind, I maintain: no overspeed detected, hence no activation of overspeed protection.
2/ I fail to see where the transcript shows the crew was aware of the stall. OTOH, there are parts which show they weren't ("comment ça se fait qu’on continue à descendre à fond là ?")

Originally Posted by A-FLOOR
My point was that with elevators alone the aircraft will drop the nose again when the elevator backpressure is released, but this may no longer be the case when the THS is trimmed fully aft.
Releasing the back pressure on the stick may be not enough, as the FBW will then try to maintain path/g load. If the stick is placed and held nose down, the nose will drop. It takes more time as long as the THS full nose-up, but it works, and if maintained the THS will come back from its "full nose-up" position.
NB: I do however agree that it's not a good idea for the auto-trim to go full nose-up when the SW is on (point discussed at lengh in one of AF447's dedicated thread).

Originally Posted by A-FLOOR
I know of no Boeing type which has an Airbus type autotrim system that automatically trims the THS to relieve pitch input. In manual flight, even the 777 and 787 have to be trimmed manually for airspeed using the trim switches. This does not take into account some functions where the trim is adjusted automatically with flap and speedbrake deployment (...)
OK, wasn't aware of that. Thx.
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Old 11th Jun 2012, 21:53
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CVR transcript

Have you read the CVR transcript?
Yes, of course.

Three years after the horrific event, and despite the fantastic PPRuNe members knowledge, F-GZCP wreckage remains incomprehensible.


IMO, here is a very interesting link where you can see both CVR and FDR transcripts.

I have printed it (3 pages needed to see some data), and also IR#3 (En) pages 29-30-31 (and take a pencil to add some "zero lines" or other line ...)


Regards

Last edited by NeoFit; 11th Jun 2012 at 21:58. Reason: Typo
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Old 11th Jun 2012, 22:17
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Originally Posted by jcjeant
This air chief pilot quote is in a video (in french) posted earlier in this thread
Thanks, now we found out it is Airbus chief test pilot, mr Rosay, could now someone please translate what he actually said, for the benefit of us not understanding French?

Originally Posted by jcjeant
Do you think this behavior normal ?
I'll refrain from definitive judgment, as I don't feel qualified enough to draw the line of normality. However, on normality scale, finding UAS so ordinary to not even report it is far, far more normal than trying to climb the aeroplane above its ceiling just because airspeed indication got messed up.

Originally Posted by jcjeant
This is in contradiction with the rules
How would anyone know what the rules were? The data is de-identified, you don't know whether there was safety management system with compulsory/confidential reporting scheme in the place at the time of the occurrences, let alone what airline did the alleged offenders fly for.

Rest of your post is completely irrelevant to AF447; it refers to earlier replacement of Rosemount probes with either Goodrich or Thales. Yup, Thales probes were found to be superior to Rosemount's.

Originally Posted by Lyman
This is iPad Facto from the releases, and not a clear finding, certainly not expressed in this way.
This statement of yours is radically at odds with the truth, as what I mentioned is clearly stated on page 65 of interim2. Interim doesn't mean it is not official. Just not final. Yet.

Originally Posted by Lyman
If this statement is casually accurate, the fault is with the regulator, via the airline. The airline is responsible, in an agency, for the regulations. The Pilots, as representatives of the line, are the visible ones, but to understand "unfazed" the culture at AF is on the hook.
The airline is not identified in the report. Your notion it's AF might eventually turn out to be correct but for the time being it's pure conjecture.

Originally Posted by Lyman
We also have not seen a procedure to follow.
Anyone suffering from this condition can be quickly and efficiently cured by gazing upon interim1, page 69 or interim3, page 59.

Originally Posted by Machinbird
Where did you get that about Yuri Gagarin?
In the article about spatial disorientation, published in internal air force magazine, some 23 years ago (if you wonder: my father was reserve captain in the army that started to crumble at the time so he could get away with sneaking away a few issues of GRViPVO to his aeroplane-crazy son). There was nice illustration, allegedly based on radar plot, of MiG-15 UTI entering the cloud, reversing its heading and completing two full spirals before hitting the ground. Point of the article, with which I fully concur, was that spatial disorientation can happen even to the best and most experienced pilots. That former fighter pilot can be offended by the suggestion is quite surprising to me. Frankly, I find it even a bit appalling.

Originally Posted by Machinbird
The whole circling thing was improvised on the spot from all appearances. Is it any wonder it didn't turn out well?
So how does it fit in with your "We are talking about trained airline pilots here" umbrage? He was astronaut, far better trained than any airline jockey, yet he died making what uninformed call "beginner's mistake".

Originally Posted by Machinbird
This looks like a Clandestino opinion piece.
Sure it is. It's my opinion based on DFDR readouts, precisely rendered on pages 29-31 of interim3. Where do you find fault in it?

Originally Posted by Machinbird
Everything I've read about PIO events indicates that it is like the aircraft suddenly seems to switch from a Dr. Jekyll to a Mr. Hyde personality
Again, I find such a notion coming form an carrier qualified ex-phantom driver a bit disturbing. Aeroplane doesn't change a bit, it is the unfortunate pilot that gets into phase with its oscillation.

Anyway, maximum roll before the aeroplane stalled was 11°, which can be called significant only by severe stretch of imagination. However, from DFDR data it is pretty clear that CM2 actively and successfully dampened the roll, therefore he was very aware of the aeroplane's bank so we can lay the theory "he did not see instruments" to rest.

Originally Posted by Lyman
Has anyone here had a singular experience in the sim, without help, in UAS recovery, though conversant in the platform's operation? Dozy?
Please everyone: read the following paragraph carefully. Reread it if it's not clear after the first reading. Come back and ask questions if still unsure you understood it. Refer to interim2 for more information.

There were more than thirty cases of UAS similar to AF447 on A330 and A340 aeroplanes. Almost all of them included autopilot disconnect and reversion to alternate law. All of them ended without damage to aeroplane or injury to passengers. Airlines involved are not explicitly stated, yet from the date of the occurrence and MSN of the aeroplane it can be easily determined. There were some incidents involving the Air France.

Therefore:
Notion that unreliable airspeed must be fatal on Airbus is false.
Notion that most of the contemporary Airbus pilots are unable to handfly the beast in alternate law at cruise level is false.
Notion that every Air France pilot is so ill prepared for the UAS on 330/340 they are bound to crash if and when it occurs is false.

Originally Posted by Sillypeoples
If I were to guess, and it's just that...lighting strike took out their avionics and fly by wire
If you were to guess only based on CVR, it would be pretty reasonable thing to assume but there is no need to do that as DFDR data is available. No electronic or mechanical failure was detected. Yes, you have read it correctly: no failure! Sensors kept on measuring the pressure which was no longer actual total, as pitot orifices were blocked by ice and that's what cascaded into AP loss and reversion to ALTN2. Per design and a good one, too.

Originally Posted by PJ2
we remain unable to say why the aircraft was pitched up and, more importantly, why it was held there when all of us who fly transports know that the airplane is going to run out of energy with the pitch attitudes recorded in the data.
That's something both CM2 and CM1 forgot just before the accident. I'm speculating but perhaps they were too knackered to think straight?

Originally Posted by PJ2
The crew did not wake up that morning intending to have an accident
Not just that. We can be pretty certain that CM2 strongly believed he was saving himself and everyone on board from a threat that he unfortunately did not name for the sake of CVR. That his actions were just the opposite of needed is beyond tragic.
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Old 11th Jun 2012, 22:22
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Originally posted by A-FLOOR ...
(in the "humbling sim experience" thread)
  • ... the captain correctly remarked on his return to the FD that the aircraft was stalled.
  • Have you read the CVR transcript?
You must be privy to a CVR version somewhat different to that published by the BEA.

The Captain did say at 2 h 11 min 52, "Well look take take that".

So why persist that the crew knew the aircraft was stalled, when there is no supporting evidence.

Last edited by mm43; 11th Jun 2012 at 22:24.
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Old 12th Jun 2012, 00:19
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It has been opined by somebody here that there's no good reason for auto-trim in ALT2B, and probably added to the confusion.
Could anybody explain the specific difference(s) between ALT2"A" (I assume there is such a thing) and ALT2B?

Standing by...
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Old 12th Jun 2012, 00:44
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mm43

Not sure re: CVR, but it was reported, among other comments, that "I understand nothing", "We have crazy speed", AND (from Captain, on return) "What are you doing, this is a Stall".

The latter did not end up in the CVR releases, but a lot of other stuff may not have as well. "Er.. What are you doing" did make the report. For now, I reject the comment re; STALL, however, unless the entirety of the audio is released, we will not know, ever. Likewise, I am unclear as to why CONFiture's comment is unaddressed: "Vmode trace" not in the record.
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Old 12th Jun 2012, 01:01
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Rest of your post is completely irrelevant to AF447; it refers to earlier replacement of Rosemount probes with either Goodrich or Thales. Yup, Thales probes were found to be superior to Rosemount's.
Not at all .. this show how much earlier (far before the AF447 event) was the preoccupation about the Pitot tube problem and it's possible consequences ....
I want to remind you what you posted
clandestino
Before AF447 it seemed that UAS is somewhere in the middle of the seriousness scale as pilots have successfully coped with it. There was no rush to change the offending pitots.
And what I posted ...
jcjeant
August 2001:
The DGAC mandates the replacement of the sensor Rosemount probes by the
Goodrich and Thales AA by AD 2001-354 (B) (Appendix 3).

July 2002:
In the OIT 999.0068/02/VHR SE (Annex 4), Airbus made ​​the observation of defects
probe Thales (formerly Sextant) P / N C16195AA.

December 2002:
The FAA mandates the replacement of the sensor Rosemount probes by the
Goodrich and Thales AA , specifying the hazard out of the flight and that is the answer to an "unsafe condition" (Annex 39)

January 2005 : Thales launch the project « ADELINE » (annexe 5). Actual air data equipment is composed of a large number of individual probes and pressure sensors. This equipment delivers vital parameters for the safety of the aircraft’s flight such as air speed, angle of attack and altitude. The loss of these data can cause aircraft crashes especially in case of probe icing.
Yes .. indeed .. despite all the earlier preoccupations .. it was unluckely no rush ......
clandestino
Thanks, now we found out it is Airbus chief test pilot, mr Rosay, could now someone please translate what he actually said, for the benefit of us not understanding French?
In the video .. the interviewer ask Mr Rosay .. what the AF447 pilots had to take as action when the event occured
His aswer was .... do nothing !
Clandestino
In the article about spatial disorientation, published in internal air force magazine, some 23 years ago (if you wonder: my father was reserve captain in the army that started to crumble at the time so he could get away with sneaking away a few issues of GRViPVO to his aeroplane-crazy son). There was nice illustration, allegedly based on radar plot, of MiG-15 UTI entering the cloud, reversing its heading and completing two full spirals before hitting the ground. Point of the article, with which I fully concur, was that spatial disorientation can happen even to the best and most experienced pilots. That former fighter pilot can be offended by the suggestion is quite surprising to me. Frankly, I find it even a bit appalling.

So how does it fit in with your "We are talking about trained airline pilots here" umbrage? He was astronaut, far better trained than any airline jockey, yet he died making what uninformed call "beginner's mistake".
Gagarin was not really an experienced pilot ... (check his flight hours ...)
And when he was incorporated in the space program .. he fly very little time .. (or not at all) just for keep up to date his pilot papers (license)

Reference
Starman by Jamie Doran and Piers Bizony
Although he was the most famous pilot in the world, he was not a particularly experienced one. Telltale clues can be discovered even to this day in the museum at Star City, where a number of Gagarin’s personal effects are preserved. His pilot’s log book is a much-venerated object, yet it makes disturbing reading. When he was recruited into the first cosmonaut squad at the end of 1959, his total flight time amounted to 252 hours and twenty-one minutes. Of this, only seventy-five hours had been spent as a solo MiG-15 pilot, first at Orenburg, then on station at Nikel in the Murmansk region. For a young Air Force lieutenant starting out on his career, this was not an especially poor total, although most of the other cosmonauts in his group had logged 1,500 hours or so. If he had stayed on active duty with the Air Force, Gagarin could have built up his flying time to become a superbly skilled fighter pilot. After he was recruited for training at Star City, however, he lost this opportunity altogether.

Last edited by jcjeant; 12th Jun 2012 at 01:50.
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Old 12th Jun 2012, 01:13
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@OK465,

Heh heh, thought I had read of it here, so I parroted it. Looking at the FCOM, I see nothing of the sort. I sit, corrected.
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Old 12th Jun 2012, 01:31
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OF:

No need for you to sit corrected. The IR refers to ALT2B.

And you are correct about the other documentation.

That's the point.
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Old 12th Jun 2012, 01:46
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Lyman,

Your quote:
AND (from Captain, on return) "What are you doing, this is a Stall".
Where did "this is a stall" come from? I don't think I have seen this anywhere. IMO, what seemed obvious, the Captain never figured out what was happening upon return to the cockpit.
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