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-   -   AF 447 Thread No. 8 (https://www.pprune.org/tech-log/482356-af-447-thread-no-8-a.html)

OK465 5th June 2012 22:11

I would add 2 things to the FD discussion...

1. They had most probably never seen a situation where the FD bars disappeared and then returned

2. As A33Zab says, the bars flash for a short period and then go steady (like the flashing lights on an ambulance can draw your attention before you hear the siren)

Most of the returns weren't long enough for the bars to go steady, but the return when pitch had finally been reduced to 5.6 degrees would have flashed AND then gone steady, possibly a falsely reassuring appearance of overall system validity...

Three more things...

1. At the apex, it would only take a couple of seconds of ill-advised following of what could have been a fairly subtle initial FD command to stall the aircraft, the subsequent initial aircraft reaction and physical flight indications not necessarily being a 'hit you over the head' indication of a valid accompanying SW audio.

2. The FD's should not have remained selected

3. We'll probably never know

Old Carthusian 6th June 2012 00:41

Franzl
The evidence there is that the PF induced that particular nose down attitude 'There, I've taken it down a bit' to quote. The human element is still the major issue here. Bringing in the FD obfuscates the circumstances and qualifies as a red herring in my book. There is no getting away from the impression that this particular flight crew was thoroughly incompetent.

jcjeant 6th June 2012 00:56

Hi,

Old Carthusian

There is no getting away from the impression that this particular flight crew was thoroughly incompetent.
This impression (if it is every bit true) leads to several questions:
Is that the system of training and selection of Air France and the french civil aviation formation should be questioned?
Is what the instructor pilots of Air France are qualified ?
Is the management of Air France has sufficient attention to these formations and selections ?
Are the aircraft manufacturer informations out dated for the conduct of flight ?
Is that the training and selection criteria are out of date and have not be adapted to contemporary needs by regulators ?
Will the BEA put in light those questions in his final report ?

CONF iture 6th June 2012 01:21


Originally Posted by Old Carthusian
The evidence there is that the PF induced that particular nose down attitude 'There, I've taken it down a bit' to quote.

Do not see evidence where there is none : The PNF is talking about the mach reduction in order to conform to the speed for turbulence, not the attitude.
A speed reduction induces a higher pitch, not lower.

Old Carthusian 6th June 2012 01:40

CONF iture
It can be read both ways and this is what I wanted to bring out. Selective reading of the evidence is never a wise thing and the truth no matter how painful it is needs to be faced. We will not know exactly what happened but the information we have points to human elements and has done ever since the CVR was decoded. Everything else is just fluff
jcjeant
Those are very pertinent questions and I think they do hit at the core of this accident. I have always thought that the Air France culture was part of the issue and the background.

Lyman 6th June 2012 01:45

OLD CARTHUSIAN:

No. And No. Retired F4 refers to the Nose Down at 2:10:00, when the aircraft was on autopilot. Hence the pilots had nothing to do with the Nose Down Pitch.

Are you now claiming the autopilot was incompetent??

If so, let's begin...

Quote (from BEA pp 88):

"...02:10:00 Pitch attitude decreases from 1.8° to 0° in 3 seconds.
Also visible in the FDR readout on BEA IR3 page 111..."



Response?

bubbers44 6th June 2012 02:06

We always should consider the autopilot incompetent. Never trust it, just use it to reduce workload but never trust it. You, the pilot,are the only thing to trust presuming you can hand fly an aircraft when automation fails.

The old guys know this.

HazelNuts39 6th June 2012 09:16

The AP just did the job assigned to it: maintain altitude while traversing an upward gust.
Image posted earlier:
http://i.imgur.com/igxsK.gif?1

Lyman 6th June 2012 09:44

HN39

For refernce only, what headwind would have been necessary to trigger Overspeed, at the 2:10:02?

HazelNuts39 6th June 2012 10:08

Lyman,

The steady headwind doesn't matter. At ISA+15.6°C a sudden head-on gust of 30 kt would have increased Mach from 0.815 at 02:10:02 to 0.866 (Overspeed warning threshold Mmo+0.006).

Please note that in two zoom-climb incidents overspeed warning was triggered without triggering the overspeed protection.

RetiredF4 6th June 2012 11:41


OC
Franzl
The evidence there is that the PF induced that particular nose down attitude 'There, I've taken it down a bit' to quote. The human element is still the major issue here. Bringing in the FD obfuscates the circumstances and qualifies as a red herring in my book. There is no getting away from the impression that this particular flight crew was thoroughly incompetent.
OC, there is no evidence at all that this phrase at 02:09:54 is related to giving up height. It could be related to the change of radar scale or the reduction of speed (most probable) but not to the altitude.

You are entiteled to make the assumption concerning FD display being a fact or a nonevent, but it´s not correct to use incorrect statements with it and disqualify stated facts of other posters (in this case the attitude of the aircraft) as being a red herring.



There is no getting away from the impression that this particular flight crew was thoroughly incompetent.
Unfortunately most of us have to agree on that statement.

AlphaZuluRomeo 6th June 2012 12:05


Originally Posted by CONF iture (Post 7228581)
Regarding the initial maneuver, it is not only the reduction in indicated altitude, but also a negative VS + an unusual low pitch for a cruising FL.

This seems to be a very reasonnable explanation indeed.

But, given the situation:
  • 360ft too low
  • pitch 0° when it should be ~2.5°
  • V/S negative when it should be 0.
How is it logical/reasonnable to engage such a climb that you get:
  • 3000ft+ too high ultimately
  • pitch more than 10°
  • V/S far too much positive

:confused:

CONF iture 6th June 2012 12:48


Originally Posted by AZR
How is it logical/reasonnable to engage such a climb that you get:
•3000ft+ too high ultimately
•pitch more than 10°
•V/S far too much positive

Sure, none is reasonnable.

In the meantime, it has to be mentioned that the initial action is suggested by the horizontal bar for vertical navigation. At this time the AP/FD vertical mode is still most probably in ALT CRZ. The negative values must have sent the horizontal bar pretty high on the PFD. What I don't get is why the system decides to dump the AP but thinks it smart to still display the FD for 3 more seconds.

In this short period, with warnings and turbulence, there is absolutely no chance for the crew to identify a case of UAS and apply its memory items.

Machinbird 6th June 2012 13:31

I am not ready to declare the AF447 crew to be incompetent, only their performance as incompetent. I can understand being a bit brain dead at 2AM.
(Seems to happens to me at work at 2AM routinely nowadays:})

A paragraph taken from the NTSB report on the AA landing incident in Jackson Hole seems to fit AF447 pretty well:

The incident highlights an issue that has arisen in recent accidents around the world: today's automated, reliable aircraft can breed complacency in pilots, the **** concluded.

A simultaneous series of events aboard the jetliner prevented its****** systems from functioning, the investigation found. The pilots, distracted by the initial failures, could have ********* had they manually ******* some of those systems, the agency concluded.

"This incident demonstrates that experienced pilots can become distracted during unusual events,"
.........and lose track of what is happening with the aircraft.

Clandestino 6th June 2012 13:36


Originally Posted by RetiredF4
Forgive me my ignorance, it was yourself, who put the discussion back to this simple term.

Because it is simple: CM2 pulled the aeroplane into stall and kept her there. That's why it fell.


Originally Posted by Lyman
alternate Law? for UAS? Why?

Because alternate laws are must-have fail-safe, mitigating the risk of untimely activation of overspeed and alpha protections! Computers are unintelligent and get more easily confused than humans, that's why they refrained from intervention when the aeroplane was stalled. Wet dream of many a PPRuNer asking for more direct control in Airbus turned out to be a hellish nightmare.


Originally Posted by LoneWolf 50
Scan and knowing what procedures to apply are better improved by repetition, eh?

Yes, but instrument scan, understanding the aeroplane's position & behaviour and manual dexterity in manipulating the controls are not inseparably connected. True, you have to be very good to in all of them, all of the time to be a good enough instrument pilot but there's no difference between instrument scan when flying manually or when AP is on (except you can get away with more easily with lazy or inexistent scan when George is in charge) and procedures can be reviewed in one's head while serenely cruising, or standbying at home or whatever. As any technical discipline, flying can only be mastered in crawl-walk-run sequence. People struggling with basic aerodynamics will have no idea what is behind the memory items, will learn them by rote just to pass the checkride and stand good chance of misremembering or misapplying them at 4:00 AM, no matter how many time they repeat the mantra.


Originally Posted by Lyman
Clandestino and Dozy are banking heavily on two pilots completely losing the ship to Stall, with nary a whimper. I don't believe it.

Being realist, I believe whether you, I, anyone else and his dog believe or not, it will not have a slightest effect on what has already happened. If anyone in cockpit recognized a stall warning for what it was and acted accordingly, we wouldn't be having this thread. Eighth.


Originally Posted by Lyman
He hadn't heard the Stall warn yet, so we can eliminate a rote response to approach to Stall, etc.....etc....

Rote response to stall warning would have saved him and everyone on board.


Originally Posted by Machinbird
Meanwhile, the aircraft has been in a stable cruise without any obstacle clearance problems and has the potential to keep doing so, so why would any sane pilot want to disrupt that process just because some of the instruments are confused?

Shock, horror, surprise, followed by panic and disorientation.


Originally Posted by Machinbird
Rote application of an emergency procedure without understanding the appropriate circumstances has downed more than one aircraft.

Yes. Rote application of wrong procedure did. Rote application of right procedure didn't, even if its application was by sheer chance.


Originally Posted by Machinbird
It remains to be seen whether AF447 is indeed the canary in the coal mine for more LOC accidents of this type.

No. Few examples of canary in coal mine were Pinnacle, Armavia, Gulf Air, Colgan, Birgenair, Aeroflot Nord, Alitalia 46 at mt Crezzo... it's just we disregarded them with a bit of applied jingoism: those killed were Russian/drunk/Arab/regional jet jockeys/Italian/turboprop drivers/ex-military/etc. Now when it happened to western built and operated widebody, amount of irrelevant and plain wrong theories put forward on PPRuNE to compensate for our inability to face the facts is amazing thing to behold.


Originally Posted by PJ2
The primary decision-point is based upon whether the safety of the flight was impacted. That is an entirely subjective matter, as is evidenced by the differences in opinions offered on the matter by those who do this work.

It's a joke, right? Some slight subjectiveness can never be totally eliminated but pilots whose estimations stray too far from objective are bound to get hurt.


Originally Posted by PJ2
The "5deg pitch above FL100" is misleading and wrong

It is not wrong and it is not obligatory.


Originally Posted by PJ2
A 5° pitch attitude isn't going to stall the airplane any time soon.

It will never stall an aeroplane as long as there is sufficient power available. With 5° pitch maintained, aeroplane climbs, power drops, AoA goes up until level-off at 5° alpha is achieved. Any aeroplane.


Originally Posted by HazelNuts39
Is that intended as a 'slap on the wrist' or do they mean 'well done'?

Accident reports indulge in neither. It is a statement claiming following the memory items is definitively not necessary for successfully dealing with UAS.


Originally Posted by 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.

>sigh< Let me try it this way: was AF447 really the only case of UAS in cruise on A330/340 fleet so we should base all our judgments about Airbus FBW cockpit design solely on it or do we perchance have some other incidents to check how other crews behaved and see whether the UAS on the Bus is really bound to be lethal by virtue of sidestick design?


Originally Posted by Lyman
The PF does not know where neutral is

To find where the neutral is, let go of stick. Were springs broken? Extremely probably not; no mention of it on CVR and CM2 successfully reduced pitch from 12° nose up to 6° before stall warning went off second time and inane pull was repeated. So no traces loss of control in pitch. Aeroplane did as commanded.


Originally Posted by CONF iture
Every reason for the PF to initially pull.

That's very selective reasoning. Once aeroplane was back at FL350 indicated, there was no reason to pull anymore, yet he pulled and pulled and pulled, reaching an apogee of FL379, 2900 ft above cleared level. If there was a reason to keep pulling, it was not on altimeter anymore.


Originally Posted by Retired F4
In FL350 a 0° pitch can be considered a nose down attitude, as the aircraft won´t maintain level flight anymore.

In real life there are: turbulence, updrafts and downdrafts. 0° pitch can be perfectly acceptable transient cruise pitch.

A33Zab 6th June 2012 14:03

Initial FD pitch bar position.
 

What I don't get is why the system decides to dump the AP but thinks it smart to still display the FD for 3 more seconds.
between 02:10:05 and 02:10:07 FD2! (RH PFD) was not engaged.

one second remain, before both FDs were not displayed @02:10:08.
for that second the Nz delta was ~ -.15g....(Nzdemand 1g - Nzactual 1.15g).
IMO FD bar position would have been ND and minor.




AMM: 22-11-00

(1) Generation of FD bar commands

(a) Pitch FD bar command

The pitch FD bar command is computed by using the measured vertical acceleration (NZ) and the NZFD command (pitch outer loop).


OK465 6th June 2012 17:12


It will never stall an aeroplane as long as there is sufficient power available. With 5° pitch maintained, aeroplane climbs, power drops, AoA goes up until level-off at 5° alpha is achieved. Any aeroplane.....
.....except an aeroplane with a stall 'angle of attack' of less than 5 degrees. :)

PJ2 6th June 2012 17:26

Clandestino;

Thank you for your responses to my comments.

Quote:
Originally Posted by PJ2
The "5deg pitch above FL100" is misleading and wrong

It is not wrong and it is not obligatory.
In reverse order... First, we're arguing the same point but for different reasons. I have always argued that the initial memory items (regarding the 5deg pitch attitude above FL100) were not obligatory but you continue to misunderstand the point of all my posts on the topic. The drill was indeed viewed as obligatory as far as the BEA was concerned (in their press conference) and as far as many on this board were/are concerned.

Note - edited to clarify the notion of "obligatory" and the execution of this drill:
The drill is obligatory in the sense that there is an abnormality and there are memory items associated with the abnormality. In this case, the first memory items are bypassed because they don't apply, because the airplane is above circuit altitude and above MSA. The memory item is, "level off and troubleshoot". It is not obligatory to pitch up to 5deg. That has always been my argument.

The point of my early and ongoing interventions was to provide reason to re-consider the assumed-obligatory nature of the drill and (see above) to question or at least think about why anyone would pitch a transport up while in stable cruise. The FCTM and various Airbus documents, some of which I have posted links to, indicate that automatically pitching up is not the correct response.

For the longest time, no one here agreed with that view and kept reaffirming that the correct response in all circumstances was first, pitch up, then re-stabilize the airplane.

The fact that a 5deg pitch isn't as harmful as a 15deg pitch-up is beside the point: Why pitch-up at all when in cruise flight just because the pilot considers that there is "immediate risk to the safety of the flight"? Where is the "immediate risk"? In my view, there is apparently far greater risk in destabilizing the airplane in cruise flight than in keeping it level, for troubleshooting. Thirty-odd other crews seem to have agreed with this view.

It is in this manner that I consider the UAS drill "wrong"...perhaps too strong a word, but the drill is, clearly, poorly-written. While others may not think so, I think that that requires an examination.

The memory drill's first question is, "is the safety of the flight at risk?" That is a crew decision which directs their response one way or another.

That is an important decision and I submit that the question, "is the flight at immediate risk" is more subjective than a decision based upon, say, flight phase. I'm trying to consider a way of making the response more clear. I considered flight phase to be a natural way to do this and gave some thought to a re-designed drill as per a recent post.

You will agree will you not, that loss of airspeed indications during the flight phase AF447 was in, is not nearly as serious as losing airspeed information during the low-altitude takeoff-initial climb phase? The intent of the pitch attitudes stated in the memorized portion of the drill was to provide immediate, safe numbers for such failure in a flight phase where looking up the numbers isn't possible. In cruise, the airplane is already established and in a stable flight phase and the crew has time to respond differently, as per the last memorized item, "when above circuit altitude or MSA, level off and troubleshoot".

Regardless, the main point I have always made and which you continue to miss is, Why destabilize a transport aircraft in cruise flight when a better course of action is to keep the pitch and power settings which existed prior to the failure? I made the mistake of stating that a pitch up to 5deg would lead to essentially the same result as AF447 and I was wrong and have corrected and stated that view a number of times. Please, move beyond my original mistake and argue if you will, from the present point being made.

Lyman 6th June 2012 18:47

In layman's terms, but no less accurate:

A decision to do nothing... is still a decision. That is the point being missed, imho.

Perhaps a bit existential, but... The stage is set for doing the wrong thing when after a career of doing nothing, it feels as though, "something must be done..."

Lack of familiarity through "hands off" can lead to danger when necessary to "hands on"....rote, memory, feel, all are crusty from disuse, and not readily available in an emergent situation..

Machinbird, step in anytime....

Flyinheavy 6th June 2012 18:49

@PJ2

[QUOTE]The memory drill's first question is, "is the safety of the flight at risk?"
That is a crew decision which directs their response one way or another.[QUOTE]

I think, they never applied this procedure anyway. They lost A/P at 2:10:05 and PF says at 2:10:14 "we haven't got a good display" to complete the phrase at 2:10:18 "of speed", while PM says at 2:10:17 "We've lost the speed etc.."
without any mentioning of UAS procedure.
If the transcript is real it shows that there was a lot of confusion and in fact no action only reaction of the PF to whatever situation he thought they were in.

As to the "There I've taken it down a bit" comment of PM at 2:09:54 it obviously refers to >Copilot's ND scale changes from 80NM to 40NM< at 2:09:53, so clearly no reference to pitch or speed as some were posting here.

PJ2 6th June 2012 20:38

Flyinheavy;
[quote]The memory drill's first question is, "is the safety of the flight at risk?"
That is a crew decision which directs their response one way or another.


I think, they never applied this procedure anyway.
We actually don't know if the PF was applying this procedure or not as his actions were never announced nor was the PNF included in what was happening as the PFs actions took place. What we do know from the CVR is that no normal/abnormal ops SOPs and no CRM procedures took place. We cannot attribute the pitch-up to anything, with any certainty, we can only consider what may be plausible or not and look for minute clues which are always interpreted. If we are not mindful in this process of attributing cause, the risk is that we get into the problems that alf5071h has made contributions on, hindsight bias, or that willingness to substitute or at least think about what we think should have happened for what we can only, actually hear and see in the recordings.

I have long posited the notion that perhaps the pitch-up was due to a remembered response in training, right after takeoff, of the UAS memory items, but there are equally interesting notions that explain the pitch-up in quite different ways.

And even after the pitch-up and before the stall the airplane was controllable using normal control inputs, (getting the nose down), but in absolute terms, the stick was in the NU position more often than it was not, prior to the stall. The potential for a complete and rapid loss of situational awareness is high in these circumstances.

To be sure, there is much more behind this than a mere pitching-up of the airplane for which we do not know the reasons. In terms of manual flight the airplane is very easy to handle at cruise altitudes and it would have been straightforward to return the airplane to cruise flight. The task is to understand why it went the other way.

gwillie 6th June 2012 23:28


Watch "Vanished: the Mystery of Flight 447," on a special edition of "Nightline" TONIGHT at 11:35 p.m. ET/PT
Air France Flight 447 Investigation: Pilots Not Properly Trained to Fly the Airbus A330? - ABC News

Machinbird 7th June 2012 01:24

Quote:
Originally Posted by Machinbird
Meanwhile, the aircraft has been in a stable cruise without any obstacle clearance problems and has the potential to keep doing so, so why would any sane pilot want to disrupt that process just because some of the instruments are confused?


Originally Posted by Clandestino
Shock, horror, surprise, followed by panic and disorientation.

Hey Clandestino, we are talking about trained pilots, not random guys you pick up on the street. The only emotion an actual pilot might experience should be surprise. If any of the other emotions are being experienced, then that person doesn't belong in a cockpit without further training to convert those negative emotions into positive and considered action. Flying is not supposed to have a lot of emotion attached to it other than appreciation for the beauties of the sky and the earth.:cool:

alf5071h 7th June 2012 01:49

From hindsight to foresight.
 
… is hindsight bias a conclusion in itself…´Lyman #1084:
Bias is a tendency to hold a view which may affect our thinking; thus hindsight bias is not a conclusion unless we consciously choose to hold that view.

If we consider foresight as a process of judgement acting on information, then we have to establish if the information necessary for the judgement was available and known by the judge. Only then can the quality of the judgement be debated. Such judgement involves risk assessment and the determination of an acceptable level of risk – as low as reasonably practical (ALARP); but then who sets the standard.

In many ways this process is similar to that in determining the level of acceptable behaviour in a ‘Just Culture’, and using Dekker’s view – “it’s not the value the line which is important, but who sets it".

Previous A330 ice crystal / ADC / ASI events may have concluded that flight into such conditions was an acceptable risk because of the non-fatal outcomes (with hindsight).
AF447 was an unacceptable outcome which suggests that foresight failed; but the process of foresight was identical with previous events, thus if this is unacceptable, what risk (information) should have been judged.
Differences between previous events and AF447 might indicate a reason for the severe outcome (what), but this only represents the additional risk in that one event. It’s the difference amongst the events before AF447 which might identify the relevant contributor to the risk (why).

One difficulty with this line of thought is that irrespective of what factors are identified and mitigated, there is still some residual risk; it is probable that AF447 fell into this category.
To progress safety the industry requires to take a more abstract view for continued airworthiness (systems thinking), vice the probabilistic based certification view; and will need to apply generic safety nets to catch residual events. Aspects of these were covered by PJ2 @ #1037.

Lyman 7th June 2012 02:08

alf5071h

Differences between previous events and AF447 might indicate a reason for the severe outcome (what), but this only represents the additional risk in that one event. It’s the difference amongst the events before AF447 which might identify the relevant contributor to the risk (why).

Are you certain you are not Santa Claus in test pilot rig? Assigning 447 an equitable position on the evidence table is kind, to be......kind.

There not only existed no foresight, there was foreblind.... Actively avoiding a field of 'best practice', the players and the odds were not in the group usually assessed as a standard statistical population.

Hindsight bias is merely a point of view, as you say, one may choose it. It has no place in a strict investigatorial venture, but this ain't that.

It is, or should be, obvious, that foresight is not quantifiable, hence subject to human failings in its application. Interdisciplinary overlay is no excuse to reduce the rigor of a culture of impeccable safety. And it is not expensive... That is the annoying irony. Most of what is lacking is merely what needs be done as part of the job description, hence, it is prepaid....

There is criminal negligence here, in spades, IMHO. Bets are off; risk management, as odious a term as it is, was nonexistent, though it was no obstacle to the mission!

I can appreciate your point of view, but analyzing 447 as a 'case study' is wildly impractical, there was no structure on which to hang the minimum.

Machinbird 7th June 2012 02:32

Lyman, if you were in charge of the AF safety program, and AF447 had not yet happened, what would your basis be for grounding the entire fleet of A330 aircraft until the pitot probes were changed out? You have perhaps 30 examples of pilots coping successfully with frozen pitots. How do you justify your position to management? How do you justify an expansion of the pilot training program to include relatively rare failures at altitude (where there should be plenty of time for corrective action by the crew.)

As I implied earlier, the legal profession tort process makes its living from peoples' inability to exercise perfect foresight.

It is relatively trivial to exercise perfect hindsight.:rolleyes:

john_tullamarine 7th June 2012 02:45

It is relatively trivial to exercise perfect hindsight

True .. which is why most of us don't get too entrenched in Monday morning quarterbacking.

How do you justify an expansion of the pilot training program to include relatively rare failures at altitude

Certainly, one wouldn't head off down a path of kneejerk training reaction.

However, one MIGHT, as part of normal, prudent risk management processes, consider whether there could be a problem ?

I would have expected Flight Standards Management (not just AF, but any operator of the Type) to have put a small sample of line pilots into the simulator to observe what their responses might have been to such events ? The outcome of such an experiment might then have suggested whatever when it comes to training program variations.

Machinbird 7th June 2012 03:15


Originally Posted by J.T.
I would have expected Flight Standards Management (not just AF, but any operator of the Type) to have put a small sample of line pilots into the simulator to observed what their responses might have been to such events ?

John, that seems eminently prudent.

As a former military aviator, there are large holes in my understanding of how the airline side of the world goes about its business.:O I try to constrain myself to stick and throttle matters.

Lyman 7th June 2012 03:42

First identify there is a problem... Wait and see seems to have been the drill. AF had (has) a leadership problem, it shows from all the ridiculous commentary post crash. Only Public Relations? No. Indicative of no one in charge.

There was a cluster of nine UAS events at AF in the year around 447. I think I'd have been tempted to organize a special program to isolate that data and use it to saturate an intensive focus by several check pilots, in parallel with Airbus pilots, and narrow the scope to creating a very strict profile of who flies where, and when, tighten up the roster on an emergency basis, and perhaps assign a safety pilot on a temporary basis to fill out the cockpit. Engage the crews who had experienced the events, put together an interim, "here's how", "do's and don'ts", etc.

No grounding necessary, though I would seriously consider a dead head home event for each a/c, similar to what UAL did when, after BA038, United's eighty eight T7s were ordered immediately stateside to undergo immediate inspection of fire bottles. The inspection was deferrable, but they hobbled their operation to do a gd line check.

I could be wrong, but the nonchalance apparent at AF was breathtaking. The crew of 447 was a wild card, that is not a difficult call to make, and issues of rest and command, experience, etc. should have been on alert until the challenge was completely quenched. Dubois had failed a check ride, ordinarily not a huge deal, but it would have flagged him (possibly) for a vacation from ITCZ flights until these events were better understood.

You could easily say this is all hindsight. I like to think that from what has fallen out, it may be ascertained that much more should have been done. Look at the flight path of each incident a/c. You fly small and fast, in the airline business, wandering around the sky is a no no. Flight Path loss is serious. No, Critical, perhaps not in and of each event, but for what it suggests, could go wrong as follow on to unidentifeied behaviour.

Old Carthusian 7th June 2012 09:23

Lyman
You're right - this is not hindsight but something which can be spotted in a professional and efficient organisation. Air France's own audit highlighted issues with flight crew but these weren't addressed. It is thus the case in all the airlines which develop corrupted cultures.

Lyman 7th June 2012 13:46

OC.

As I see it, there are no facts that haven't happened; everything we write is based (or suggested by) facts. Looking back is looking back, forensics. BEA may have some suggestions, but with management/leadership issues, it's more difficult. Culture is squishy, v/v regulation.

PJ2 7th June 2012 15:56


Looking back is looking back, forensics.
I think so.

What about this as one working understanding:

There is no "hindsight bias" in examinations of the recorders or other factual records. It is only "bias" when we substitute or subtlely (or not) dress the facts with what we think should have been done "but wasn't".

Theories about what happened and why are not hindsight bias because they are just that: theory. Theory describing possible/plausible cause(s) is not fact until established by what is known from the record.

Bias is revealed by statements like, "I can't believe that a crew could...", or, "Why didn't they...", or "Well, obviously...", and promotes what we think, perhaps even logically so and from our experience, should have happened, and proceeds from that point towards discussions of cause(s), under the assumption that it is still proper investigative technique.

Clearly it is more complicated than this and there are areas of cross-pollination which are difficult to steer clear of or engage in.

Turbine D 7th June 2012 16:14


As I implied earlier, the legal profession tort process makes its living from peoples' inability to exercise perfect foresight.

It is relatively trivial to exercise perfect hindsight.
So very, very true!


First identify there is a problem... Wait and see seems to have been the drill. AF had (has) a leadership problem
and,

You could easily say this is all hindsight.
You are correct, it is hindsight. The analytical mind has great trouble retracting data that can be mostly recalled from memory while at the same time offering a should'a, could'a, would'a commentary.


Lyman
You're right - this is not hindsight but something which can be spotted in a professional and efficient organisation.
Yes it is hindsight and here is why!

You need to both go back and review the data presented in the BEA Interim report #2, starting on page 65. There you will learn there were indeed 9 events on Air France aircraft where loss of speed indication at high altitudes occurred. Seven events occurred between May 2008 and October 2008. All were on A-340 aircraft. You make it seem Air France sat on its hands and did nothing which was not the case at all. After the first event in May 2008, the second occurred in July 2008. Air France reported to Airbus the incident after the July 2008 occurrence and events thereafter. Air France then reported to Thale the worsening problem in October 2008. Then two new events occurred, one being the first one on an A330 aircraft. After ongoing discussions between parties including EASA, Air France on April 27, 2009 issued a modification to replace all pitot probes on all their long range A-340/A-330 aircraft with the first replacement batch of probes arriving a week or so before the AF447 accident. Review the tables of known events, at the time of the BEA report, starting on page 100 where at least 2 pitot tubes were blocked with ice.

So, which aircraft would receive priority in the change out of pitot tubes, the A-340 or the A-330? Wait, we can't answer this question without a bias of hindsight. Only the planners at Air France who developed the change out program can...

Lyman 7th June 2012 17:32

Let's look at a parallel in the business world. NFL Football.

Highly skilled professionals are demanded to perform to maximum limits, and carry this mission through the year, no let up. Each "flight" occurs on one day/week, generally. The action is technical, physical, and mental. Post game, there is INTENSE forensic activity, by the professionals, their guidance team, (coaches) and to a lesser extent, support staff. The goal is to improve on an already excellent effort. Status quo effort gets people fired....

Films, interviews, comparisons, computer, medical, etc. It is ALL hindsight.

Without looking backward, there is total waste of effort v/v an improvement, perhaps in small increments, but without constant improvement, there is backsliding, into a "who cares" culture that gets ridiculed, and eventually swallowed up.

Competition in aviation is cutthroat, as it should be. The loss of safety goals from the competitive landscape is dangerous, for in aviation, losers don't just get released, sometimes they die, and take a portion of the audience with them.

I am trying my best to understand what is wrong with a look back? Is it because someone is looking who is from the outside? You cannot police yourselves, you are not well regulated by those who are entrusted to do so. Perhaps it is time for outsiders to see the evidence, examine, and make judgments?

Defending a system that is under attack is to be expected. It is possible we will never agree; I get the impression there is a stance of apologia here, based on the straw man of "hindsight bias".

Hindsight? Bias? So stipulated, then. Shall we move along to acceptance, and discussion, rather than wasteful attempts to de-certify?

TurbineD. I have run across doctored photographs purporting to be from IR2. May we PM?

Organfreak 7th June 2012 17:45

Lyman wrote:


Let's look at a parallel in the business world. NFL Football.
Let's not and say we did.

Football is just a game.
Flying hundreds of people through the troposphere @600 MPH in a "tin can" is not a game; it's (can be) a deadly exercise.

Sometimes I feel like you must instruct us all, constantly, at length, with your ideas, as opposed to facts. I don't want to block anyone, but you wear me out, buddy! Chill?

jcjeant 7th June 2012 18:17

Hi,

Turbine D

You need to both go back and review the data presented in the BEA Interim report #2, starting on page 65. There you will learn there were indeed 9 events on Air France aircraft where loss of speed indication at high altitudes occurred. Seven events occurred between May 2008 and October 2008. All were on A-340 aircraft. You make it seem Air France sat on its hands and did nothing which was not the case at all. After the first event in May 2008, the second occurred in July 2008. Air France reported to Airbus the incident after the July 2008 occurrence and events thereafter. Air France then reported to Thale the worsening problem in October 2008. Then two new events occurred, one being the first one on an A330 aircraft. After ongoing discussions between parties including EASA, Air France on April 27, 2009 issued a modification to replace all pitot probes on all their long range A-340/A-330 aircraft with the first replacement batch of probes arriving a week or so before the AF447 accident. Review the tables of known events, at the time of the BEA report, starting on page 100 where at least 2 pitot tubes were blocked with ice.
AF .. Airbus ..EASA .. Thales .... even DGAC ..
One actor is missing ... the BEA
Where are inquiries .. investigations and reports (recommendations) of the BEA concerning all the pitots events (incidents) concerning french registered aircraft prior AF447 event ?

OK465 7th June 2012 18:23

It's interesting that people are willing to pay a lot of money to sit in a seat that is not necessarily so comfortable, but is 'relatively' safe, at an NFL football game...and that as a result, an individual in a 'profession' which predominantly values sheer physicality over intelligence is rewarded with a handsome life style for doing nothing more than entertaining.

As contrasted to sitting in a relatively more comfortable seat, which is 'relatively' less safe...

I guess you get what you pay for.

Lonewolf_50 7th June 2012 18:28

Points raised that got me thinking again:

Once aeroplane was back at FL350 indicated, there was no reason to pull anymore, yet he pulled and pulled and pulled, reaching an apogee of FL379, 2900 ft above cleared level. If there was a reason to keep pulling, it was not on altimeter anymore.
As before, the unanswerable "what was he seeing" during this time segment comes to mind.

The fact that a 5deg pitch isn't as harmful as a 15deg pitch-up is beside the point: Why pitch-up at all when in cruise flight just because the pilot considers that there is "immediate risk to the safety of the flight"? Where is the "immediate risk"? In my view, there is apparently far greater risk in destabilizing the airplane in cruise flight than in keeping it level, for troubleshooting. Thirty-odd other crews seem to have agreed with this view.
While all thirty of the other crews were not AF, what is the likelihood that all 30 or so events were shared and understood by crews at the time? Many no doubt were familiar with them via however safety reports and updates are distributed ... but how well understood? Probably unknowable.


Why destabilize a transport aircraft in cruise flight when a better course of action is to keep the pitch and power settings which existed prior to the failure?
IN the thread that alludes to "another 447 avoided" that same question can be asked, given the altitude excursion they experienced. Perhaps the crew in that incident has an answer?

What we do know from the CVR is that no normal/abnormal ops SOPs and no CRM procedures took place.
An AF training/cultural issue. (Could also be termed a standards and standardization issue).

After ongoing discussions between parties including EASA, Air France on April 27, 2009 issued a modification to replace all pitot probes on all their long range A-340/A-330 aircraft with the first replacement batch of probes arriving a week or so before the AF447 accident. Review the tables of known events, at the time of the BEA report, starting on page 100 where at least 2 pitot tubes were blocked with ice.
This hull was perhaps a few weeks away, maybe a few months away, from its tubes being replaced.

Ouch. :{

HazelNuts39 7th June 2012 19:30


Originally Posted by Lonewolf50
IN the thread that alludes to "another 447 avoided" that same question can be asked, given the altitude excursion they experienced.

In the two 'level bust' incidents the zoom-climb was mostly automatic. In the AF incident the PNF in response to an overspeed warning accidentally disconnected the AP and gave a brief pitch-up input on the sidestick.

Turbine D 7th June 2012 20:19

Hi jcjeant,

Where are inquiries .. investigations and reports (recommendations) of the BEA concerning all the pitots events (incidents) concerning french registered aircraft prior AF447 event ?
Perhaps the answer lies in the first paragraph of the BEA mission statements.

The BEA (Bureau d'Enquêtes et d'Analyses pour la sécurité de l'aviation civile) is the French authority responsible for carrying out safety investigations relating to accidents or serious incidents in civil aviation.
The statement pertains to French aviation investigations or international aviation investigations where French citizens are involved and where the BEA would be a participant in the investigation but not the leader.

In the instance of the pitot tube events, none of the nine, involving French airlines, were considered to be serious incidents or incidents that resulted in accidents requiring investigation, if I interpret correctly.

I am just reading from the BEA's mission on their English homepage.


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