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AF 447 Thread No. 10

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Old 17th Mar 2013, 14:33
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two more parts for the whole report
Where are they?
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Old 17th Mar 2013, 15:40
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jcjeant, you may not like it, but the BEA mission is not to disclose everything they got their hands on.
The mission is to analyse the facts and provide a report including recommendations as to how avoid a repetition of the facts (and the final accident).

Now, about the judicial report (not read entirely), it contains a synthesis of the flight (§6.3). I quote it below: Dozy, it might be easier to translate without copy/paste errors from the PDF.
The report also contains a more detailled description & analysis in its §6.2.x but that is too long to be quoted here.

Du décollage au FL350

La route suivie est conforme au plan de vol et se déroule conformément aux prévisions.
Un défaut de toilettes, sans conséquence, est transmis automatiquement au centre de maintenance d'Air France.
Le vol est sans turbulences notoires.


En croisière jusqu'au point INTOL

A cette heure de la nuit, alors que la charge de travail est faible et que la fatigue se fait sentir, l'équipage remplit les obligations de la préparation de la traversée de la zone ETOPS sans dynamisme.


En croisière du point INTOL à l'arrivée de l'OPL de renfort

Malgré les interrogations formulées par l'OPL PF, le CdB ne s'implique pas dans la conduite du vol et n'apporte pas de réponse sur la conduite à Venir face à la masse nuageuse identifiée sur la route.


De l'arrivée de l'OPL de renfort à la première alarme

Le CdB est passif lors de la relève et laisse le PF faire le briefing.
Le PF conscient de l'importance de la masse nuageuse informe le PNC.
Le PNF analyse la situation et prend l'initiative du choix de l'évitement latéral.


De la première alarme au décrochage

02h08'00" à 02h11'04"
Les actions de l'équipage sont en lien avec l'environnement constaté et aux informations disponibles mais ne répondent pas à une procédure en vigueur sur ce type d'avion.

02h10'04" à 02h10'14"
L'équipage réagit sans stress apparent à la première alarme en restituant une procédure connue et assimilée : contrôle de la trajectoire et actions immédiates.
L'accumulation des messages, associée à des alarmes sonores successives perturbe la perception de la situation.
L'OPL PF poursuit les actions initiées dans la séquence précédente pour la protection des moteurs, mais l'OPL PNF ne participe pas.
L'alarme STALL est perçue avec surprise sans diagnostic ni actions liées.

02h10'14" à 02h10'26"
L'équipage fait le constat, sans analyse, de la perte des indications de vitesse.
L'effet de surprise lié à l'alarme STALL qui retentit une deuxième fois est fort.
Face à l'incompréhension de la situation, le PNF cherche dans la lecture partielle et désordonnée de l'ECAM une justification à ce qu'il perçoit, et revient à son projet d'action initial de prévention des conditions givrantes.
Les perceptions de l'équipage ne sont pas suivies d'un diagnostic. En conséquence aucun traitement de panne n'est initié.
Le PF est concentré sur le maintien de l'inclinaison en raison de la loi directe en roulis et n'assure plus la maitrise de la trajectoire dans le plan vertical.

02h10'26" à 02h10'32"
L'alarme C-Chord initie un processus Perception-Diagnostic-Décision-Action partagé par l'équipage et cohérent pour l'écart d'altitude supérieur à 300ft.
Le vocabulaire inadéquat révèle une augmentation du niveau de stress.
Le mode de réversion V/S conduit à avoir des des barres de tendance centrées.

02h10'32" à 02h10'49"
Le PNF guide le PF pour la maîtrise de la trajectoire verticale en s'appuyant sur un diagnostic validé, mais change de projet d'action sans s'assurer de la mise en descente réelle de l'avion.
La commutation des sources ADR et IR est la recherche d'une information valide et non le résultat d'une analyse ou l'application d'une procédure.
Les barres de tendances sont centrées pour une assiette de 6° et une vitesse verticale de 1400 ft/mn en montée.

02h10'49" à 02h11'12"
L'équipage composé de deux OPL n'a pas fonctionné suivant la répartition des tâches définie pour un équipage composé d'un CdB et d'un OPL.
Le PNF s'est focalisé sur le retour du CdB pour retrouver une hiérarchie habituelle d'autorité.
La procédure STALL WARNING n'a pas été appelée.
Le suivi de la barre de tendance profondeur du Directeur de Vol a contribué au maintien d'une assiette à cabrer forte.


Du décrochage au retour du Commandant de Bord

02h11'12" à 02h11'42"
L'équipage perçoit la situation anormale niais ne peut élaborer un diagnostic en raison d'éléments contradictoires : Alarme STALL, pleine poussée, assiette affichée en accord avec les barres de tendance.
Le pilotage avec les seules références basiques du VSV* n'est pas assuré par le PF.
Les indications du Directeur de Vol sont toujours à cabrer.
La perte de contrôle est réelle, perçue par le PF comme une vitesse élevée et par le PNF comme la perte des commandes de vol du coté PNF.
L'avion est hors du domaine de vol connu. Dès lors la possibilité de sortie du décrochage ne peut être établie.

* VSV : vol sans visibilité, terme utilisé pour le pilotage à l'aide des seuls instruments (sans références extérieures)


Du retour du Commandant de Bord à la fin des enregistrements

02h11'42" à 02h12'13"
Au moment de l'arrivée du CdB dans le poste, la situation visible et audible ne reflète pas ce que l'équipage a vécu jusqu'alors.
Tous les éléments sont réunis pour créer une situation incompréhensible, aggravée par l'affirmation du PNF « On a tout tenté », sans pour autant dire ce qu'ils ont tenté et pourquoi ils l'ont tenté.
Le PF est resté sur le schéma mental de la survitesse, le PNF prend l'autorité et réagit à l'alarme STALL en appliquant la poussée CLIMB. Le CdB a une attitude passive.
A cet instant, il ne peut être établi que l'avion est rattrapable.

02h12'13" à 02h12'26"
Le CdB n'a pas de diagnostic de la situation, et ne peut répondre au PNF qui le sollicite.
Le PF retrouve une attitude (assiette et inclinaison) qui lui fait dire qu'il a le contrôle de l'avion.
L'alarme STALL a un fonctionnement inversé pour une vitesse mesurée inférieure à 60kts.
La tension devient perceptible au sein de l'équipage.

02h12'26" à 02h12'44"
Le stress intense devient perceptible, la communication au sein de l'équipage utilise un vocabulaire non conventionnel qui ajoute à la confusion.
Les informations visibles valides sont rejetées et le segment perception-diagnostic de trajectoire en montée n'est pas partagé par le PF.
Le fonctionnement inversé de l'alarme de décrochage ajoute à la confusion sur l'action sur le manche et le pilotage de l'avion.
La loi ALTERNATE 2B reste active hors du domaine de vol connu limitant l'action de la gouverne de profondeur et perturbant la stabilité longitudinale naturelle.

02h12'44" à 02h13'18"
La tension devient plus forte au sein de l'équipage où la synergie est absente.
Le PF manifeste son désaccord sur les remarques de ses collègues sur son pilotage. Il alerte sur l'altitude en descente.

02h13'18" à 02h13'59"
La divergence de diagnostic est manifeste. Le PF alerte sur le fort taux de descente, le PNF est orienté sur le bon fonctionnement des commandes de vol, le CdB ne prend l'initiative à aucun moment.
La configuration de l'avion ne permet plus la récupération du décrochage.

02h13'59" à 02h14'27"
Dans cette phase ultime l'équipage réagit conformément à l'alarme de proximité du sol.
The report also includes a CVR transcript. Noteworthy: even the jucidial report respects the privacy included in european reglement 996/2010.
BTW, there is no meaningful difference between the BEA's and the judicial's reports transcripts.
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Old 17th Mar 2013, 15:46
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Where are they?
The two missing parts:
Report part 2
http://aerofuites.com/exp-jud-juin-2...e-techniqu.pdf
Technical annexe
http://aerofuites.com/exp-jud-juin-2...que-du-29-.pdf
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Old 17th Mar 2013, 16:34
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PJ2 sez:
hi gums;
Yes, the gang's all here, but only momentarily!
No I'm not!
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Old 17th Mar 2013, 17:21
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Quote from CONF_iture:
"Full CVR audio does not belong to the public but it belongs to the front crew.
Full CVR audio + full FDR data have to go to the pilot at the same time they go to the investigative body + manufacturer.
If I die on my job, I want my wife to have my data.
Too painful it will be for her to listen to the tape, but I have Friends I trust she can provide the information to, making sure every one is keeping honest in his duty."



While I heartily agree with all that as an aspiration, is it all established in law?
Are you allowed to share them with others, and are there any restrictions on that?
And, in the event of your death before your receipt of it, does your next-of-kin inherit your rights?
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Old 17th Mar 2013, 17:47
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jcjeant,

Thank you for the two remaining parts.
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Old 18th Mar 2013, 00:11
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Originally Posted by Chris Scott
In a few thoughts :
Law is not necessarily to protect the little guy.
To keep our institutions honest is the role of the citizen or the little guy.
The media should play that role too but belongs now to the big guy ...
What happened on my flight deck has to go to the investigative body and the manufacturer which makes sense, but what could justify full data is not going to me as well or the one on my short list ?
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Old 20th Mar 2013, 06:54
  #1028 (permalink)  
 
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Originally Posted by HazelNuts39
It would be easier to understand your discourse, if you could tell us what those areas are.
Sorry HN. Did not see this right off. I was not ignoring your question, which is reasonable.

First, let me say I have gone through the type course and had plenty of simulator time and more on the A320 series not that long ago. The AI FBW is an ingenious system and while I will admit not being a fan going in, I came to appreciate the immense amount of very clever programming that goes into making the FBW system a transport pilot's best friend 99% of the time. I tell you this so you know where I am coming from.

One of the things I discovered during my 'indoctrination' was there are times when you are not fully in the loop and have to trust the process as you monitor. This is not a knock on the AI FBW system. It is a symptom of the larger problem of automation in general and it cuts across aircraft brands and types. Pilot’s groups and unions have known about this for over two decades, but as an industry, we are just beginning to understand the need for a tighter coupling of the man machine interface and the importance of keeping current our manual flying skills - getting back to the basics. Some never left that place of surety, particularly the old timers amongst us, but many of us could easily be caught in the trap of not “using it” and “losing it.”

I believe the evidence produced so far clearly indicates the crew of AF447 were out of the loop from the start, and it appears they were caught in a trap of mostly their own doing, however I also strongly feel their aircraft or training , most likely both, let them and their passengers down in what turned out to be the worst way possible and it was the combination of these factors that led these otherwise competent pilots, down the garden path. I strongly feel the BEA should have explored this aspect of the accident further. The report should have included data and analysis of the several documented instances of unreliable airspeed and known pitot issues across the fleet to better understand how this critical sensor failure manifests itself in real life.

Three paragraphs on, and finally to your question HN. What more could the BEA have done in preparing the report, outside of the above sentiments I offer? The published DFDR traces are entirely too coarse at roughly 30 seconds per ½ to ¾ of an inch. By statute, the DFDR on this category aircraft is required to provide a sampling of the pitch, yaw, and roll inputs and their corresponding control surface positions at a minimum rate of 2 hertz, with 4hz being standard for these channels. That's 2 to 4 samples per second. As to the other available channels, the raw CG trim fuel data might be interesting to know. An additional set of engine parameters beyond N1 might be useful. The AOA and airspeed plots are a mess as are the control input traces, the former group mostly due to the erroneous data but all three groups further muddled by the coarse scale that was chosen. The EFIS state is marginally presented, but a bit of a mystery remains as to exactly what was seen in the cockpit that night and when.

I see a renewed interest in the CVR transcript. This is one of the most sensitive areas of accident data. As far as I know, nearly all ICAO member countries share similar legal requirements for the handling of the CVR audio and transcripts. Other than photographic or descriptive evidence of human remains, the CVR audio is the most protected data set of the investigation. The BEA seems to have done a reasonably fair job in sharing this most sensitive part of the accident investigation.

Last edited by vapilot2004; 20th Mar 2013 at 07:01.
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Old 20th Mar 2013, 09:11
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va 2004, you have figured it out. I thought only old pilots like me could do that. Good for you.
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Old 20th Mar 2013, 11:22
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vapilot,

Thanks for your reply.
The report should have included data and analysis of the several documented instances of unreliable airspeed and known pitot issues across the fleet to better understand how this critical sensor failure manifests itself in real life.
BEA's Interim Report no.2 provides a detailed analysis of thirteen preceding UAS incidents that were adequately documented. The judiciary experts have interviewed the pilots involved in some of these incidents and describe how those pilots perceived the situation.

The main body of the BEA final report contains some very detailed graphs of the areas that really matter. Other DFDR data are shown on a smaller scale in the appendix and include pitch, roll and yaw input and control surface deflection at the recorded sampling rate, which is equal to or higher than the values you mention. If you have difficulty with the graphical scale, use the 'zoom' function of your pdf viewer. The graphs do show all relevant parameters in sufficient detail to permit an understanding of what took place.

There is no indication of any abnormality in the engine behavior, nor of the pilots even looking at the engine parameters. So how would additional engine parameters contribute to a better understanding of what happened?

EDIT: As to AoA and airspeed being a mess - the plots show the actual data points as they were recorded, without any filtering or 'interpretation', except that the graphics software added a thin line connecting each data point to the next.


The report also shows, to the extent possible, what was to be seen on the EFIS, for both pilot's stations. What was actually seen by the pilots can only be derived from their comments as recorded by the CVR and documented in BEA's report.

Last edited by HazelNuts39; 20th Mar 2013 at 12:25.
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Old 20th Mar 2013, 17:38
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BEA's Interim Report no.2 provides a detailed analysis of thirteen preceding UAS incidents that were adequately documented. The judiciary experts have interviewed the pilots involved in some of these incidents and describe how those pilots perceived the situation.
Yes indeed
Question:
Is that those documented reports were in the hands of AF before AF447 accident and if so .. is that the AF pilots were briefed ?
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Old 20th Mar 2013, 18:35
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.jcjeant,

it's all in the final report of the 'coll`ege d'experts'
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Old 20th Mar 2013, 19:35
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HazelNuts39
.jcjeant,
it's all in the final report of the 'coll`ege d'experts'
Yes I know also that .. and that is why I wondered why your answer to Vapilot was incomplete
Vapilot
Thanks for your reply.
Quote:
The report should have included data and analysis of the several documented instances of unreliable airspeed and known pitot issues across the fleet to better understand how this critical sensor failure manifests itself in real life.
HazelNuts39
BEA's Interim Report no.2 provides a detailed analysis of thirteen preceding UAS incidents that were adequately documented. The judiciary experts have interviewed the pilots involved in some of these incidents and describe how those pilots perceived the situation.
As the reports of the experts show that AF did not give alot of importance to these documented reports and did not follow a timely manner has its pilots before the AF447 accident.
Error of judgment ?
Poor risk assessment ?

Last edited by jcjeant; 20th Mar 2013 at 19:38.
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Old 20th Mar 2013, 21:15
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jcjeant,

my discussion with vapilot is about a "multitude of unpublished areas" in the BEA reports. Unless vapilot tells me otherwise, I think my reply to his last post was sufficiently complete.
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Old 20th Mar 2013, 21:28
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Originally Posted by jcjeant
Error of judgment ?
Poor risk assessment ?
It's hindsight being 20/20. It's quite ignorant pointing to precursor incidents as proof that the big one could have been predicted and prevented. It is not as if Thales probes getting blocked was the only problem on 330/340 fleet. In real life hundreds of incidents happen every day, just a few developing into emergency and very, very small fraction of them leading to disaster. Out of thirty-something UAS in 330, only one involved damage and injuries.

Originally Posted by vapilot2004
I also strongly feel their aircraft or training , most likely both, let them and their passengers down in what turned out to be the worst way possible
What are you basing your feeling on?

Originally Posted by vapilot2004
I strongly feel the BEA should have explored this aspect of the accident further.
In what manner?

Originally Posted by vapilot2004
The published DFDR traces are entirely too coarse at roughly 30 seconds per ½ to ¾ of an inch.
So? Do you believe higher resolution would yield completely different picture?

Originally Posted by vapilot2004
the raw CG trim fuel data might be interesting to know.
Why? It is perfectly clear aeroplane responded to control inputs, too aft CG would accelerate demise by a second or fraction thereof but it would be pretty irrelevant in the grand scheme of things.

Originally Posted by vapilot2004
An additional set of engine parameters beyond N1 might be useful.
What for? Engines work as advertised. What difference would oil quantity or ITT margin make on stall event?

Originally Posted by vapilot2004
The AOA and airspeed plots are a mess as are the control input traces, the former group mostly due to the erroneous data but all three groups further muddled by the coarse scale that was chosen.
Actually reading the report would help to dispose of this nonsense. There are three different timescales included in the report.

Originally Posted by CONFiture
Law is not necessarily to protect the little guy.
Since this is not law but aeronautical forum, I'll concentrate on flying aspects: little pilot guy is best protected when he knows and understands his aeroplane and medium he is traveling through. Failure to do so more often causes his demise than anything else.

Originally Posted by CONFiture
What happened on my flight deck has to go to the investigative body and the manufacturer which makes sense, but what could justify full data is not going to me as well or the one on my short list ?
If we take for granted that you or anyone on your short list can indeed do more for aviation safety than officially appointed expert teams, well then there really would be no reason.
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Old 20th Mar 2013, 23:37
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Out of thirty-something UAS in 330, only one involved damage and injuries.
So if it is so rare this kind of accident .. I wonder why there was so much noise around this accident .. why change the probes .. why procedures were reviewed .. why new training .. for a case so commonplace
Why all the fuss about ?

If we take for granted that you or anyone on your short list can indeed do more for aviation safety than officially appointed expert teams, well then there really would be no reason.
Empowering censorship (because it is one of the powers of the BEA) may appear plausible for some case
Nevertheless we will never know the justifications for censoring .. they can be legitimate or illegitimate
This is a double-edged weapon

Last edited by jcjeant; 20th Mar 2013 at 23:51.
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Old 20th Mar 2013, 23:44
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@jcj : The Service Bulletin mandating the replacement of the Thales AA probes was in effect *before* the AF447 accident. If I recall correctly, the accident aircraft was scheduled to have the work done in the following month or two.
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Old 21st Mar 2013, 13:11
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Originally Posted by jcjeant
I wonder why there was so much noise around this accident ..
Mostly made by those handicapped by inability to understand the circumstances leading to it. Why do they feel the need to parade their ignorance is beyond my powers of understanding.

Originally Posted by jcjeant
why procedures were reviewed
To improve them. Something that happens when old ones are discovered lacking. Usually we don't need crash to do it, incidents serve as reminder well enough. Now for sciolists: there were crews who ignored stall warning as spurious and kept the attitude; there were crews that pulled but quickly reverted to push when warning went off. AF447 was the only one that both pulled and ignored stall warning and in that matter it was unique among the A330 crews but not among other crews flying "classic controls" aircraft who performed such a feat before them.

Originally Posted by jcjeant
Empowering censorship (because it is one of the powers of the BEA) may appear plausible for some case
Do you care to provide reference to your interesting viewpoint or you'd rather have us believe you because you said so?

Originally Posted by jcjeant
Nevertheless we will never know the justifications for censoring
Probable cause: imagination running wild.
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Old 21st Mar 2013, 15:50
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Do you care to provide reference to your interesting viewpoint or you'd rather have us believe you because you said so?
Already discussed extensively
BEA has censored the CVR transcript .. what is in the public domain is a censored version
Why some parts are censored ?
Because it is the prerogative of the BEA
Thus the BEA can censor it considers necessary .. and did not provide a justification
Why BEA censorship that part and not another .. nobody can tell ...
By definition .. censorship is hiding or removing certain things ...
The truth can not accommodate things hidden or secret
When things are hidden or secret .. the consequence is imagination running wild .. that can be avoided by exposing the all truth .. not by censoring ..

Last edited by jcjeant; 21st Mar 2013 at 15:58.
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Old 21st Mar 2013, 16:14
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@jcj:

As I'm sure you well know, "censored" is a loaded term, usually with negative connotations.

The fact is that every CVR transcript ever released into the public domain as part of an accident investigation report has been abridged to some extent. This is - and has always been - true of reports released by not just the BEA, but also the NTSB, ATSB, AAIB and TSB Canada to name but a few. If you consider what the BEA has done to be censorship, then you must also conclude that the transcripts released by all of the above have also been censored.

Personally I think it's the wrong term to use, due to the aforementioned negative connotations. The reason all transcripts are restricted to the portions that are relevant to the conduct of the flight is because the pilots' unions demanded it as part of the agreement to making CVRs mandatory on transport-category aircraft.
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