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AF 447 Thread No. 10

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AF 447 Thread No. 10

Old 24th Mar 2013, 22:33
  #1061 (permalink)  
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The notion of "amoral calculation" was discussed in Diane Vaughn's work, "The Challenger Launch Decision: Risky Technology, Culture and Deviance at NASA". The notion expresses the common worry and perception that "bean-counting, profit-seeking managers" will drive instrumental priorities in spite of clear evidence of outcomes in terms of deviance, failure, incidents and accidents.

Vaughn found that contrary to her beginning premise (that managers at NASA were expressing an amoral calculation in their operational work), there was almost no evidence of cynical wrong-doing motivated by profit but only the best intentions towards the goals at hand. From Vaughn:
Repeatedly, I was struck by the difference between the meaning of actions to insiders as the problem unfolded and interpretations by outsiders after the disaster. As I gained an understanding of cultural context and chronological sequence, many actions, much publicized and controversial, took on new meaning. Incidents that when abstracted from context contributed to an overall picture of managerial wrongdoing became ordinary and noncontroversial. For example, after writing a 1978 memo objecting to the joint design, Marshall engineer Leon Ray helped develop corrections to the joint that assuaged his concerns, leading him to believe that the design was an acceptable flight risk. Ray's memo became part of the official record creating the impression that managers had been overriding engineering objections for years; his subsequent action did not. Now alert to the importance of relocating controversial actions in the context of prior and subsequent actions I expanded my focus beyond its restricted attention to rule violations. (Vaughn, p. 60)
The other notion that Vaughn pioneered (but which we in this business are familiar with by other names) is the "normalization of deviance". For those new to the notion, one way of expressing the meaning is, the reducing of margins of error in standardized proven systems because the standard can successfully be reduced while maintaining sufficient margins of error. (There are other ways of expressing this of course!).

So rather than nefarious activities behind engineers' backs, most managers could claim to be onside with the safety people but they also knew that they had to be mindful of schedules, budgets, regulatory affairs, government politics and public perceptions. As you would expect these are very bright and aware people but none of that guarantees that phenomenon such as normalizing standards through "reasonable justifications" is the right thing to do. Often it is seen as "amoral", and calculated towards pedantic goals only in hindsight.

The recent review of the "courses of action not taken" regarding in-orbit video and photographs of Columbia concerning the wing damage, (initially discussed in papers in Starbuck's and Farjoun's "Organization at the Limit: Lessons From the Columbia Disaster") is one such clear example - a sad one showing that NASA had not fully learned the lessons of Challenger ten years earlier.

If I were looking for a place in organizational dynamics that could lead to present circumstances, (your point about "mostly stuff what experienced old school pilots learned" etc), I would view a relatively unquestioned stance towards the privileged place of technology in present-day operations. Such a question is not informed by what we could call the "fiscal discourse" yet it appears to mimic the effects of "bean-counting" priorities. That way of putting the question leaves the issue open to recognition of the good that technology contributes positively, while examining the permissions we grant technology in terms of the relinquishing of control, all of which can lead to an inappropriate reliance and which, as we know well, will (not may) let us down at the most critical moment.

I think the industry has been changing for some time now - ie., returning to the old ways while keeping technology, and the RAeS lecture is recognition of this and as such is indeed information in aid of this change.

That doesn't mean that pure bean-counting decisions which dismiss safety in favour of commercial gain aren't made. I've seen it happen, (despite senior managers seeing the FDA data.) However from what I saw the other side is by far the weightier one!

I know from conversations with those doing the work, (I'm retired) that this knowledge has been in the simulator scripts and training courses for some time now. I'm less confident that an abiding mild skepticism regarding automation is making similar inroads but I think it is moving inexorably in that direction.

Last edited by PJ2; 24th Mar 2013 at 22:59. Reason: punctuation;Vaughn quote
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Old 25th Mar 2013, 09:40
  #1062 (permalink)  
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I wonder myself, in the briefing was nothing new on the planet, mostly stuff what expierienced old school pilots learned about stalls amd falls from the beginning regardless whether it was civil or military. Was this knowledge completely lost and has to be invented again?
How long will it take to make the findings and results available to the line? And still i´m concerned, that it will again end up in some fixed procedure without transfering te knowledge which led to the developement of said procedure.
I agree that it was mostly well known facts, but although I count myself "a practitioner skilled in the art"(of aerodynamics) I still learned some new things about how stall testing is done these days. I don't think it is a question of knowledge being 'lost' - flight testing is a continuous process and what was being presented was more a statement of the accumulated wisdom of the two flight test departments. Seems to me that your concerns really relate to the transmission of this expertise to the guys who actually fly these machines every day.

That said, I'm not sure how much line pilots need to know about actual flight test stalling techniques but of course the descriptions of typical stall and post stall behaviour were and are relevant.

I'm shooting my mouth off here, because I have no experience whatsoever in this area, but to an outsider it seems that there is sometimes an important gap in the information trail from manufacturers' flight test expertise through their training departments to airline training departments to line pilots. Not just on stall behaviour; there are other examples where inherited wisdom was not passed on.

Pilots will no doubt be able to put me straight on that
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Old 25th Mar 2013, 12:32
  #1063 (permalink)  
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It was not my intention to downplay the important work of test flight departements, though posted in this thread my focus was more what it will provide to the end user.

We are in full agreement on your following statement.

Owain Glyndwr

.......... but to an outsider it seems that there is sometimes an important gap in the information trail from manufacturers' flight test expertise through their training departments to airline training departments to line pilots. Not just on stall behaviour; there are other examples where inherited wisdom was not passed on.
@ PJ2 I see your points, now tell me what will change and who will initiate the change? there are lots of saying like ..... my company is doing that and that .......i practice that and that.... and so on. Schouldn´t those necessary changes in training and qualification be regulated and monitored to a necessary standard?

Last edited by RetiredF4; 25th Mar 2013 at 12:38.
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Old 25th Mar 2013, 15:43
  #1064 (permalink)  
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Re, "now tell me what will change and who will initiate the change? there are lots of saying like ..... my company is doing that and that .......i practice that and that.... and so on."
I guess I'm not quite clear on what you're searching for. Isn't that how change occurs and isn't this what has been occurring for a long time now? A discussion on the elixir and ultimately the industry's addiction to automation, like any such human behaviour, requires a pretty firm intervention which does not occur everywhere, or at once.

I apologize for the length of these posts - it's pretty dry reading I'll admit but the answers to the kinds of issues you're raising are complicated and can't be captured in a nut-shell, so to speak.

Re, "Schouldn´t those necessary changes in training and qualification be regulated and monitored to a necessary standard? "

Regulators are necessary certainly, but notably and notoriously lag behind such needs as are being expressed here. The aviation industry, people, companies and groups on the other hand take individual initiatives to increase flight safety where the need is indicated and do so proactively (Safety Reporting systems, Flight Data Monitoring & Analysis), and obviously reactively.

This is where change comes from - small steps, quietly taken.

Rarely does the industry wait for the regulatory intervention before taking action. For example, as I have pointed out a few times, in Canada under the CARS, training, demonstration and checking a candidate's response to the approach-to-stall is not required in PPCs on fly-by-wire aircraft. I have offered the thought in discussions that this makes no sense, first because there is nothing magic about fly-by-wire, which can stall an airplane just as easily as hydraulically-powered controls can and second, even a protected airplane can stall, as we now know, (so the elixir of automation was reinforced in at least one country's air regulations). The assumption in this regulation regarding PPCs is that somehow, fbw "protects" one against the stall, which we know is not true. It is software add-on "protections", (for gums, "limits"!), that are at work in the B777 and Airbus types.

But I know for a fact that practically-speaking, in Canada the approach to the stall has been and continues to be trained, practiced and checked in PPCs in 'Airbus aircraft and all other types, (at least at the carrier with which I am familiar) notwithstanding the absence of the requirement to do so.

Another example - the FAA's "minimum hours" rule came a long time after the industry began dealing with issues which arose out of inexperience, poor training/checking and the worst aspects of poor implementation of SMS Programs, (where in this regard the regulator discovered that oversight was still necessary because such implementations are very complicated and "self-reporting" needs a lot of maturing before the regulator can step back).

Within months of the AF447 accident, I know that some airlines were ensuring that crews were being exposed to, trained and checked in these procedures; - the manual-handling issues were quite rapidly brought to the fore as well.

My thought in the post above was first to deal with the notion of the bean-counter-as-amoral-calculator, not that such behaviour doesn't exist - it does, but that it is not the norm; most people working in a system intend to do their very best within the context in which they are employed. The point is, the causes of aberrant (meaning unsafe or leading to risk of unsafe outcomes) do not necessarily always come from parsimony but from misunderstood goals and contexts. As an airman you already know how aircrews can and do react to penny-wise / pound foolish cost-savings.

Like you I agree fully with Owain's statement that you've quoted but those circumstances don't arise out of bean-counting behaviours. Such failures to communicate seem to come from a lack of appreciation of what information in flight test work may or may not be useful and required information for daily line operations. While complex, airline operations are very much like rabbit trails - extensive but narrowly-focused on the needs of the daily operation. Recurrent training is expected to look after the contingencies and abnormalities. With few exceptions this was my experience and although not universal, is largely the case in the west.

So, it isn't as though the regulator shouldn't be setting the standard; it's just that the standard is often set long before the regulations formalize and standardize the standard...so to speak, (my brother who is an engineer always observes that that is the nice thing about standards...so many to choose from).

Last edited by Jetdriver; 26th Mar 2013 at 04:41.
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Old 25th Mar 2013, 23:17
  #1065 (permalink)  
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