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.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.

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?

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:

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.

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.

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:

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.

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.

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.

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.

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.

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.

So very, very true!

and,
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.

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...

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?

Lyman wrote:

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?

Hi,

Turbine D
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 ?

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.

Points raised that got me thinking again:
As before, the unanswerable "what was he seeing" during this time segment comes to mind.
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.

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?
An AF training/cultural issue. (Could also be termed a standards and standardization issue).
This hull was perhaps a few weeks away, maybe a few months away, from its tubes being replaced.

Ouch. :{

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.

Hi jcjeant,
Perhaps the answer lies in the first paragraph of the BEA mission statements.
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.