DaveReidUK

"casually inferred" ? what on earth does that mean ?

bubbers44

He probably didn't know how incompetent the pilot in the left seat was. With an equally incompetent pilot in the right seat pulling up into a full stall it was all over. Hopefully we haven't reached this state in the US. We are getting close with the pilot mills qualifying pilots who really can't really fly without automation.

We need to hire real pilots that don't need automation to fly. I know they were all qualified to fly but by what standards? Knowing which button to push?

DozyWannabe

And when persuasion failed, the next thing to do should have been to take control, especially if one thinks that the conduct of the flight is becoming dangerous. It was the (possibly subconscious) decision to defer actively taking control until after the Captain returned - by which time the situation had got significantly more dangerous, and the PNF himself seemed to have been confused into indecision - that I was referring to.

@bubs - There you go again with "No pilot would X", and throwing around accusations of incompetence - the PF was a highly-qualified sailplane pilot, and to the best of my knowledge gliders don't have automation. Yes, he lacked training in high-altitude manual handling, but that's a long way from "not knowing how to fly". As such, a more likely explanation was that he was overwhelmed by the situation - compounded by startle effect.

As we touched on not long ago, even pilots who are considered to be super-competent can, typically when under significant pressure, make horrendous mistakes - probably the most infamous being the KLM Captain (Chief training Captain on the 747, no less) who tried to take off without clearance at Tenerife in 1977. So a pilot doesn't need to be incompetent to foul up, but - and this is one of the reasons I respect the responsibility you lot carry - in aviation you only need to foul up once at the wrong time to end a career, a reputation, and hundreds of lives.

bubbers44

OK DW they were both totally competent pilots. You must be right because somebody signed them off to fly without the captain in the cockpit. I am sure everybody agrees with you.

wozzo

Interesting problem, but it's hard to find an answer beyond personal opinions and sensitivities. Why did PF pull into a stall? Even the Human Factor Group at BEA didn't find a convincing answer. He maybe thought of an overspeed situation. But how did he come to this conclusion? And why didn't PM stop this catastrophe?

Were they incompetent? They passed all tests, and there were no incidents that we know of. Where they competent? Well, at least the lack of situational awareness and bad CRM doesn't show Air France as a breeding ground for good practices.

I think (speculate) that Bonin had an acute attack of fear of falling down, i.e. panic (the professional term "startle factor" is just an euphemism). That's something pilots (I'm not one) probably don't talk about very much, because people who like to fly don't suffer in any meaningful way from it, it's trained away, and experience does the rest. But I'm asking if somewhere in the old "reptilian" brain regions something is still screaming (but not heard): "That's dangerous now, leaving the ground!".

I also wonder if it's a factor that Bonin previously was on vacation with his wife (fiancee?) on board. BEA noticed his nervousness in the 2 hours preceding the event. So maybe his mental state wasn't completely in "pilot mode", and the professional barriers broke down more easily.

PJ2

wozzo;

On July 27, 2011 when the 3rd Interim Report came out with the flight data and we saw for the first time what actually occurred, I posited the notion that the PF increased the pitch because that what he was taught in his last (A320) sim session when given this problem. I maintain that the memory drill for UAS is confusing and poorly-written. It has in fact been modified prior to the accident, clarifying how the drill will be done, as has the way it is taught since the accident.

IIRC, his training for the UAS event was right after takeoff. The memorized pitch attitude is 15° and TOGA for those circumstances. Rather than climb on board the another hamster wheel, the original post is here.

Many disagree with this notion but I have seen no other explanations with greater plausibility and lots of psychological etc explanations which may or may not be true. I believe that he believed he was doing exactly as he was trained, uncertain though the stick inputs were, but did not have the experience to know what was about to happen to the energy of the aircraft. If he had pulled to 5deg as the checklist seems to indicate, (and then when above MSL or circuit altitude, level off for troubleshooting, which is what cruise altitude already is), I think it would have not resulted in the stall. I think he kept pulling because the airplane wasn't at 15° - all in all a series of inputs that speak to uncertainty and hesitation.

As I have pointed out numerous times, likely in all eleventeen threads on this accident, cockpit discipline, meaning their SOPs and CRM, fell apart instantly and that in my view is the root cause of the accident because, by following SOPs, (ECAM drills, paper drills, status, etc etc) and using correct CRM procedures to maintain discipline and sort out the problem before independently leaping into (unknown) individual actions, the accident could have been prevented because there were a number of points along the pathway to the stall that would have altered the course of this accident had such been employed.

Again as I have pointed out numerous times, a UAS event is NOT an emergency and does not require instant, un-coordinated, undisciplined action. It is not an engine fire, a depressurization, an hydraulic failure etc. The airplane itself does not 'care' what the airspeed indication is.

I am certainly not going to argue the "competent-incompetent" case. I have been in and seen too many things in 35 years of flying tranports and had sufficient personal "lessons" offered by the airplane I was flying to ever place myself in a position of judging. However, the basics of successful transport flying are, (and have never wavered from being) Standard Operating Procedures, and, since late eighties, Crew Resource Management, and these were/are no doubt heavily emphasized at AF as at all other carriers, neither of which this crew carried out when it came time to do so. I am unconvinced of "startle" - everyone is 'startled' to begin with - I have experienced a massive hydraulic failure on the same equipment and yes, it was initially startling but one reverts to training and deals with the ECAM accordingly. I have no idea why it came apart so swiftly and we'll never know. All we can do is re-emphasize what would have saved this airplane, this crew and these passengers, because this was not an emergency and there was no requirment to do anything other than ensure the airplane was stable while the ECAM drill was done according to Airbus SOPs. A pitch-up to 5° would not result in a stall so even if the PF had done the drill correctly, the accident likely would not have occurred. Anything after the airplane was stalled is untravelled territory and nobody can offer advice except that which is already in the books, specifically, if you have a high rate of descent that cannot be arrested by pulling back, you are stalled and need to unload the wing and reduce the angle of attack to unstall the wing, and then be very gentle on the pull-through.

All of this and more from many others exists in the AF447 series of threads. I genuinely hope we are not on another hamster wheel.

bubbers44

You can not blame training on pilot actions because pilots should know before the airline job how to handle an airplane. They should just need differences training and SOP's for that airline.

wozzo

Really don't want to start the hamster wheel again, but ...

… I remember that, and it would tell us that Bonin indeed had a plan (if the fatally wrong one). But just for clarification: That wouldn't explain the behavior *after* the stall warning went off (considering hat Bonin had a few seconds before realized that he indeed was climbing), would it?

PJ2

wozzo, please see my above post which I have edited and added remarks.

The best we can hope for is realistic suppositions as to "reasons why". There is nothing on the CVR that would settle this beyond the improbability of another's interpretation of the words.

When we first tried out the UAS checklist in conversion training it became very apparent that it was confusing. It still has that potential but we now have an accident that may settle some minds as to what to do. But I would never, ever pull a transport aircraft even to 5deg pitch with a UAS event and said so a couple of weeks after the accident, because it destabilizes a stable airplane. Leave pitch-and-power alone because the airplane was fine moments before the data got lost. The systems will sort themselves out during and after the ECAM actions but the airplane itself as a physical entity had all the energy and thrust it needed to continue to destination, without airspeed indications etc etc. There are numerous alternate ways, long discussed, in how one might determine speed and maintain altitude with such indications lost.

Lest anyone shudder at the re-arguing of this view, fear not. It's done.

bubbers44

At high altitudes no pilot would have a pitch even approaching 5 degrees. They went over 20 so of course stalled. They were of course fully qualified pilots on their airline. Makes you wonder doesn't it?

Mr Optimistic

....makes me wonder what the Captain was doing when he could more usefully have been in his seat.

DozyWannabe

Guys - the mods merged a thread from R&N into this one. There was nothing in that thread that was not covered in this one - or the previous ten threads on the subject. I highly recommend we leave it be.

bubbers44

MO, he needs to not exceed duty time, therefore three pilots are required. He can not be on duty the whole flight. It is illegal for over an 8hr flight.

Mr Optimistic

True but it didn't have to be just then and there are some oddities to the events. At least one of the pilots was anxious for his return and questioned the delay in returning and there is no mention in the released transcript of his reference to being bell'ed back or having just got his head down. Still, no need to upset Dozy

Chris Scott

Hi PJ2,

Good to see this October Inquest discussion, including your two posts, finding its proper place in Tech Log.

Thanks for reminding us all of the deficiencies of the UAS memory drill (and even the written procedure) current at the time, and the probability that it encouraged the initial pitch-up.

As I've said before, I also wonder if the APPARENT sudden loss of about 300 ft of altitude (due to the removal of correction for airspeed when the IAS went AWOL) might have provoked a knee-jerk (of the wrist) response. But the realisation that this was just another of those UAS events should quickly have dawned, followed by a return to the familiar pitch-attitude for cruise flight. As you say, simply maintain the status-quo...

Inappropriate initial reaction is one thing, but what happened after AF447 had completely vacated FL350 climbing was irrational and inexplicable in a competent pilot who had spent many hours monitoring the flight instruments in the cruise and step-climbs on dark nights - much like the one in question.

DozyWannabe

Question : If the PF was consciously following the prescribed procedure for UAS - then why did he not, at any point, tell his colleagues he was doing so?

In fact one of the overriding perceptions of the sequence as a whole was that there was never at any point a co-ordinated effort to troubleshoot and apply procedure. When the PNF stated "you're going up", the PF did not respond with "I'm following UAS procedure" - which would in all likelihood have unlocked the mystery for the PNF and allowed for corrective action.

As a non-pilot I am constantly and sympathetically aware that I cannot feel the visceral hold to the idea that there must have been some reasonable explanation for the actions of the PF. I accept that there's a possibility that he was applying a half-remembered UAS procedure, but for the life of me I cannot understand why he would not say he was doing so.

Machinbird

The aircrew actions in the AF447 accident seem strange to those of us looking back on this accident.

There are a few observations I would like to make about the situation that this crew faced. I think the known facts do not contradict this view, but I am working from memory and it's been a while since I reviewed the accident, so feel free to correct me where I stray from the facts.

First, let us start with the PNF, Robert. He had just been awakened from sleep by the Captain and had been told that the guy flying the aircraft would be in charge. He was undoubtedly awake, but I suspect he was suffering from sleep inertia and was not fully "with it." When the A/P and Autothrottle disconnected, he had been sitting in the seat for about 10 minutes. He was aware of the mishandling of the aircraft, particularly the upward roll of the altimeter numbers and tic marks but was really not mentally locked on to the actual altitudes they were going through, thus his strange comment, " You are going up, so go down." Maybe it is just my old fashioned way of flying, but I would have thought he would have said something like 'You are 1500' above assigned altitude. Get the nose down!' His reluctance to take control might well have been a result of his sleep inertia which he would have been aware of. Likely he did not yet trust himself to perform.

Then there is Bonin, the PF. He was suddenly thrust from quietly monitoring the instruments into NOISE.
The cavalry charge, then the C chord altitude alert, and a few chirps from the stall warning on top of that. No sooner did he grab the stick and begin to correct the roll angle when the aircraft over-responded in an unfamiliar way and he began a roll oscillation. (Alt2b Law was now in effect) The aircraft was in roll direct. He apparently he had no prior experience in flying in Alt2b Law in the simulator at altitude and likely, no experience in flying in Direct law at altitude. As a result, his mental model of the aircraft response was out of calibration and his control inputs were well beyond appropriate for roll.

I do not know how many of you have experienced a roll PIO in any setting, or for that matter any PIO (pilot induced oscillation). From my one roll PIO experience in an early simulator, I found it to be extremely startling and attention getting and I would expect that Bonin experienced a similar feeling of startlement and concern. This likely fully focused his attention on the roll problem to the exclusion of almost everything else. His solution to the problem was to try to get ahead of the oscillation. It eventually worked after 30+ seconds of fighting the aircraft, but one of the reasons it worked is that the roll response was decreasing as the aircraft slowed. (The preferred solution is to stop aggravating the aircraft)

It is very likely that Bonin's nose up efforts were initially inadvertent as he struggled with the roll, then later, deliberate as he either reverted to seat of the pants flying or started flying the flight director. His thought processes were not logical by then and he was focused on a narrow part of his surroundings to the exclusion of almost all else.

By this point in time Bonin was in full fight or flight mode and Robert was getting concerned as well. They were not working together and the aircraft was departing controlled flight and they were entering test pilot territory.

My personal opinion is that if Bonin had not overcontrolled the aircraft initially, the accident would not have happened. He would have begun to follow his training, however imperfectly and the crew would have begun to work together sufficiently well to continue the flight. The lack of experience in direct law at altitude was a key contributing factor that allowed a roll PIO to develop, and from there, it all snowballed downhill.

DozyWannabe

You could be right, but the query I have regarding this is that - while my only personal experience of the flight deck is in a simulator - the spring loading on the sidestick means that if roll is all you want to control then the springs will hold you steady at zero in the Y axis unless you make an effort against them. Even in Alt2b law, the aircraft will try to maintain the last commanded pitch so there is no need to keep pulling back to maintain it.

The sidestick on an A330 is a far cry from the kind of cheap controller you can pick up for your computer - it's a chunky piece of kit!

rudderrudderrat

Hi DW,
Correct.
However some some crews move their seats after take off into a more "comfortable" position. This places their hand and arm in a completely different position relative to the side stick. I think that's why Bonin inadvertently applied light back pressure whilst he struggled to hold wings level in Alt Law.

Since the crew didn't turn off the FD switches, when the FDs automatically reappeared, they were in modes HDG & VS. The crew seem to have simply continued to follow those erroneous commands.

HazelNuts39

From memory - the BEA looked into that and established the seat position from the post-crash marks on the seats recovered.